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Hemodialysis Special Interest Group Networking Session:
A European Perspective on Vascular Access Management

Judy Kauffman, RN, CNN, is Clinical Director, Acute Dialysis/Apheresis Unit, University of Virginia, Charlottesville, VA. She is ANNA’s Hemodialysis Special Interest Group Leader and a member of ANNA’s Central Virginia Chapter.

Betsy King, MSN, RN, CNN, is Clinical Services Specialist, DaVita, White Plains, NY. She is a member of ANNA’s Northeast Tri-State Chapter and was ANNA’s Hemodialysis Special Interest Group Leader when this contribution was written.

“Fistula First” is a term we all know well in the nephrology community and we are all striving to improve vascular access in our work areas. We had the opportunity to hear from an expert in Europe and how their fistula program has been a success. Attendees at the ANNA 2005 National Symposium who participated in the Special Interest Group (SIG) Networking Session “A European Perspective on Vascular Access Management” had the opportunity to share their experiences with Fistula First Initiatives. Jean-Pierre Van Waeleghem, a nephrology nurse manager with 40 years of nephrology experience, facilitated the session.

The European Study Group

Jean-Pierre Van Waeleghem, is a nephrology nurse manager at the Nephrology/Hypertension Department at the University Hospital in Antwerp, Belgium. He presented information from a collaborative study conducted in more than 15 European countries on vascular access management.

Data were collected on 1380 patients over 57 months. The frequency of access complications ranged from 15.5% for arteriovenous (AV) fistulae to 37.5% for AV grafts. The complication rate for catheters was 27.5 %. Complications included thrombosis, stenosis, and infection; 19% of the patients experienced a complication requiring intervention. In 29% of these patients, the complication resulted in loss of the access. In AV grafts, thrombosis and stenosis were frequently observed. In catheters, infection and flow problems were frequently observed.

European Dialysis and Transplant Nurses Association Recommendations for Renal Nurses
The initial focus needs to be on protecting the arm veins for access placement in patients approaching end stage renal disease. Arms that are suitable for access placement should be preserved at all times. The use of hand veins is recommended for venipunctures and IV injections. Each facility should have a “protection plan” in place for preserving arm veins. Nephrology nurses should insist on an AV fistula as the first choice of vascular access.

In considering the best location for access placement, the forearm should be preferred as the first choice location for a native vascular access. There must be early referral of patients to the vascular surgeon to allow time for access placement and maturation of the access. The vein must be at least 2.5 mm in diameter for a fistula placement. A new fistula should be allowed to mature for at least 6 weeks and, if possible, to mature for 12 weeks.

A pre-selected puncture technique needs to be determined on each access. In Europe, the buttonhole technique is the preferred choice for cannulation. The same experienced nurse establishes the buttonhole for the first 2 weeks. There are advantages to having the same nurse cannulate the new access: fewer hematomas, less pain, fewer missed cannulations, less infection, less scar formation, and shorter bleeding time postdialysis treatment. The buttonhole technique is recommended for accesses near the elbow, upper arm, or those that are difficult to cannulate.

The rope ladder technique is the recommended method for AV fistulae in the forearm with a longer area for cannulations. Increasing the diameter of the fistula needle and decreasing the length of the fistula needle help attain the goal for high blood flow rates. Patients with accesses with venous pressures greater than 180 mmHg at a blood flow of 300 mL/minute at 2-3 measurements experienced a higher rate of stenosis and thrombosis. Regular monitoring of venous pressure, whether static or dynamic, is recommended.

The use of catheters for permanent vascular access should be avoided as much as possible. The diameter of the catheter should be a 10 french due to fewer complications. The 12 french catheter had a higher infection rate, higher stenosis, and more flow complications than the 10 french catheters.

To prevent infection, cleanliness of the access is strictly adhered to in Europe. The patients are responsible for cleansing their access with soap and water prior to going to the dialysis chair. European dialysis centers have placed sinks in the waiting area to accommodate patients cleansing their accesses. The use of masks by the patients and the nurses is recommended during connection and disconnection of dialysis catheters.

Vascular access observation by a nephrology nurse should be performed at each dialysis session. Before dialysis, a physical exam of the access should occur. During dialysis the monitoring of blood flow should be done along with monitoring of the arterial and venous pressures. The nurse should perform another physical exam of the access after dialysis and document the bleeding time for the puncture sites.

European dialysis units have all-nurse staffs and are able to focus on the effects of nursing care on patient outcomes.The next research study will focus on measuring these effects.