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(K) V
Content
Definition VA for hemodyalisis
Epidemiology and Opportunity VA for chemotherapy
Indication VA for nutrition
Contraindication US guided insertion technique
Anatomy
Historical Development
Site of intertion
Vascular Access
Definition
insertion of
catheter into the
vessel (artery or
vein) for certain
aims.
Epidemiology and Opportunity
Epidemiology Opportunity
20 million patient’s receive The creation and maintenance of
vascular catheters per year functioning vascular access, along
with the associated complications,
3 million central venous
constitute the most common cause
catheters/yr of morbidity, hospitalization, and
2030: 2.24 million patients with cost in patients with end-stage renal
ESRD. disease
Aging population with diabetes
increase ESRD patient
increased
Annual cost in USA 1 billion US
dollar.
Indication and
Contraindication
Indication Relatif contraindication
1. Hemodialysis ✺ Coagulopathy
2. Chemotherapy ✺ Allergy to the catheter material
3. Nutrition
4. Fluid administration ✺ Mediastinal tumor
* p<0.001
** p<0.007
Upper arm grafts have a high flow rate and a low incidence
of thrombosis.
higher incidence of ischemia in the hand
higher rate of stenosis, secondery to endothelial
hyperplasia.
Pros and Cons of
Catheter as Access Types
Pro Contra
No cannulation high risk of bacteremia
less flow volume (through
dialyzer ml/min)
high potential for central
vessel occlusion
cannot shower/swim
Pros and Cons of
Fistula as Access Types
Pro Contra
minor surgery high initial failure rate
little dysfunction attributable flows initially not better
very low risk of infection than catheter
longest average patency of all initially difficult to
access types cannulate
seals and heals post
cannulation
Pros and Cons of
PTFE Grafts as Access Types
Pro Contra
moderately low risk of more traumatic surgery
infection edema/pain
can be used in 2-3 life patency mean
weeks 18mths-2yrs
low initial failure rate
flows reliably high
initially easier to
cannulate & monitor
The Reality of Vascular
Access
There is no single access that meets even most of the
ideal criteria
Surgically created accesses, fistulae and PTFE grafts,
do however yield more reliable flows for adequacy
with much less risk of bacteremia
DOQI guidelines make fistulae the access of choice
Attributes to facilitate
cannulation
• Placed or transposed in an accessible body part
• Superficiality of graft or vein - easily palpated and
visualized
• tunneled in an even plane
• tunneled with gradual curves
• should provide reasonable amount of accessible surface
area to allow rotation of needle sites
Collaborative Care of
Vascular Access
Surgeons have a role as vascular access advocates
through:
diagramming new accesses
communicating specific access orders directly to the
nurses
visiting the dialysis units to do patient & staff education
and to familiarize staff c surgeon’s point of view
be readily accessible for consultation
Nutrition and
Chemotherapy VA
Perypheral IV access: For Peripheral TPN, maximum
Chemotherapy infusion
Complication of perypheral
32
Cannulation
Extravasation The
leakage of high osmolarity
solutions or chemotherapy
agents can result in
significant tissue
destruction, and
significant complications
Risks/Benefits of CVC Placement
Indications for central Contraindications for
venous catheter (CVC) placement of a CVC
Inadequate peripheral Altered skin integrity
vascular access Anomalies of the central vasculature
Cancer at the base of the neck
Need for frequent vascular
Cancer at the apex of the lung
access
Immunosuppression, septicemia
Hypertonic/hyperosmolar Problems with coagulation
infusions Clavicle fracture
Infusion of irritating or Hyperinflated lungs
vesicant drugs Radiation to the insertion site area
33
Central Catheter Positioning
Catheter tip should terminate in the superior vena cava
Catheter tip must never rest within the right atrium
Could traverse the sinoatrial (SA) node
Dysrhythmia
34
Main types of Central Venous
Access Devices
38
PICC dressing
Totally implantable vascular access
Definisi:
Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation. Annals of Emergency Medicine
1997;29:331-6
Ultrasound access techniques
“Static” “Dynamic”
mapping technique views needle entering vein
freehand
no sterile technique needle guide
required for US requires sterile technique
Position patient as you will for Place gel in palm of sterile glove
procedure Place vascular probe in palm, avoid
Look at vessels and confirm trapped air bubbles, and wrap free
landmark-predicted anatomy fingers out of way
Mark location, note depths and Sterile KY jelly for glove-skin
angles interface
Remove ultrasound, prep patient Two potential approaches:
without moving Transverse
Vein cannulated as usual Longitudinal
Internal jugular
Femoral vein
thank you