Maintenance hemodialysis (MHD) is one of the treatment methods for chronic kidney disease patients. Vascular access is the prerequisite for the smooth operation of hemodialysis and is referred to as the "lifeline" for MHD patients. It acts as a bridge connecting the patient's blood to the dialysis machine. A good vascular access is not only crucial for successful dialysis treatment but also an essential part of patient health management.
I. Types of Vascular Access
The commonly used long-term vascular accesses in clinical practice include autogenous arteriovenous fistula (AVF), graft arteriovenous fistula (AVG), and tunneled cuffed catheter (TCC); the short-term vascular access includes central venous catheter (CVC).
· AVF: Surgical connection of the patient's own artery and vein.
· AVG: Use of artificial or autologous vessels to connect the artery and vein.
· TCC: Surgically connecting the catheter closely to the skin.
· CVC: Usually used while waiting for other types of access to mature or in emergencies.
II. Establishment and Selection of Vascular Access
Currently, there is no absolutely ideal type of vascular access. All types can effectively remove toxins. Doctors consider the patient's vascular condition, overall health, and dialysis needs to determine the most suitable type of access.
Research data shows:
· Initial vascular access choice: Over 60% of patients initially use CVC.
· Long-term vascular access choice: AVF is preferred in China, followed by TCC. AVF has a long lifespan and fewer complications. However, some patients' own vascular conditions are poor, making it difficult to establish or maintain AVF long-term. TCC is widely used clinically due to its immediate establishment, long-term use, simplicity, low risk, and adequate blood flow.
III. Daily Care Measures for Arteriovenous Fistula:
1. Regular Cleaning and Disinfection of the Access Area: Maintaining good hygiene habits and keeping the skin around the vascular access clean and disinfected is key to preventing infection.
o After dialysis, keep the puncture wound dry, remove the bandage/gauze after 12-24 hours, and observe for bleeding at the needle site.
o If a hematoma occurs at the puncture site, apply ice on the day of dialysis to stop bleeding and relieve pain, and apply heat (not exceeding 50°C) the next day.
2. Observe for Abnormalities: Check the access area daily for fever, redness, swelling, discharge, pain, or other abnormalities. Report any abnormalities to a doctor immediately as they may indicate infection or thrombosis.
o Self-check the fistula daily for a thrill sensation or listen with a stethoscope for a "swishing" sound. If it is silent, seek medical attention immediately.
o Regularly undergo ultrasound checks to monitor for thrombosis in the vascular access.
3. Avoid Compression and Injury: Patients and medical staff should take care to avoid placing heavy objects near the access and ensure the access area is not subjected to friction or compression.
o Do not measure blood pressure, hang heavy objects, or wear bracelets/jewelry on the affected limb.
o Avoid wearing tight clothing and protect the fistula area from impact, using sleeves or other protective gear if necessary.
Daily Care Measures for Medium- and Long-term Catheters:
1. Sterile Technique: Catheters can be left in place for over a year. Strict sterile techniques must be followed during handling to avoid infection.
2. Observe for Abnormalities: Check the catheter site daily for redness, fever, pain, suture detachment, or dressing seepage. Report any abnormalities to a doctor immediately.
3. Avoid Damaging the Catheter: Do not use alcohol-based solutions for disinfection or handle the catheter with serrated clamps/hemostats.
o Keep the wound dressing dry and clean. If the dressing gets wet, disinfect and change it to prevent infection.
o If there is a large amount of air in the catheter upon aspiration, it may indicate damage or dislodgement. Clamp the catheter immediately, notify a doctor, and prepare for potential catheter removal.
IV. Care Focus for Catheters in Different Locations:
1. Catheters in the Neck (Internal Jugular Vein, Subclavian Vein):
o Use sponge baths or showers, avoid baths or soaking. Wash hair while lying down to avoid wetting the wound.
o Wear loose and front-buttoned shirts, avoiding pullover garments to prevent tugging on the catheter.
o Use protective gear to secure the catheter end and avoid movement, which can cause bleeding or skin infection at the puncture site.
2. Catheters in the Groin (Femoral Vein):
o Minimize leg bending and getting out of bed to prevent catheter kinking and venous blood return obstruction, which can cause catheter blockage.
o Use sponge baths to avoid wetting the wound and causing inflammation or infection.
o Wear loose inner and outer pants to avoid pulling the catheter during dressing changes.
o Keep the perineal area clean and avoid wetting or soiling the wound during urination/defecation, changing the dressing if necessary.
The effectiveness of hemodialysis is closely related to the quality of vascular access. Poor-quality vascular access not only affects the normal progression of hemodialysis but also easily causes complications, placing psychological, physiological, and financial stress on patients. Learning and mastering care knowledge, along with multi-faceted cooperation, is the key to ensuring unobstructed and long-lasting vascular access.
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Let’s continue learning more about hemodialysis in the next issue!
References:
1. Qin Moli, Care of vascular access in hemodialysis patients. Health Preservation and Healthcare Newspaper. 2024-01-01, 15, Prevention Guide.
2. Lai Yuhui et al., Application effects of different types of vascular access in maintenance hemodialysis patients. Chinese and Foreign Medical Research. 2023, 21(31), 147-150.
3. Fu Hua et al., Observation of the effect of the vascular access care team model on the psychological state and quality of life of maintenance hemodialysis patients. Guizhou Medicine. 2022, 46(04).
4. Jin Qizhuang et al., Chinese expert consensus on vascular access for hemodialysis (2nd edition). Chinese Journal of Blood Purification. 2019, 18(06), 365-381.
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