*6.3.6 CVC assessment*

CVC, despite being considered the worst HD VA, is used in a considerable number of patients, up to 80%, either due to the need to start HD following emergency catheter placement or due to lack of native vessel to create an AVF or place an AVG. The goal of performing a HD treatment via a CVC should be the achievement of the best patient outcome as possible, while keeping all possible complications under control. For this purpose, it is fundamental that all team members are familiar with the principles of CVC care, which include assessment, usage, surveillance and maintenance.

**43**

*Vascular Access Management for Haemodialysis: A Value-Based Approach from NephroCare…*

The exit site of the CVC must always be inspected at each HD treatment for any signs of irritation, infection or development of allergy to dress or disinfectant solution, including tenderness, skin peeling, rash, swelling, exudate and redness. European Renal Best Practice (ERBP) recommends to always ensure the area being cleansed around the exit site is slightly larger than the final dressing and include the

There is a wide variety of different types of products for dressing and securing CVCs, but the superiority of one over another has not yet been demonstrated. According to ERBP, for long-term catheters sterile gauze is preferable, for enabling

Before starting the HD treatment, the patency of the catheter should be evaluated. The locking solution use in the previous treatment should be removed by withdrawing 3–5 ml, locking solution mixed with blood. Using a 10 ml syringe filled with 0.9% NaCl, a small amount of blood should be aspirate into the syringe and observed for clots containment. If yes, flush should not be done. If unable to flush the physician should be alerted to assess and, if necessary, provide intervention.

Before needle insertion in an AVF/AVG, proper needle-site preparation should be done to reduce infection rates. Site selection should be done prior to the final

The most important procedure is the cannulation of an AVF/AVG, and over the course of a day, it is carried out on numerous occasions by the dialysis nurse. Choice of the correct cannulation site and technique are fundamental factors for an optimal

Tape the needle in place on completion of insertion, secure it using a minimum of three strips of tape: one to fix the wings, a second on top of it to secure the needle

The procedure of needle removal by the nurse is as important as the cannulation of the AVF. Needle withdrawal must be done carefully to prevent tearing of the vessel, to minimise access trauma and to achieve optimal HS. The needle should be removed using the same inclination as the insertion angle. Appropriate pressure should be applied after complete needle removal (thrill should be felt above and below the site

of pressure). The pressure must be hold for 8–12 min without checking.

section of the catheter that will be underneath the dressing [147].

*DOI: http://dx.doi.org/10.5772/intechopen.84987*

maximal natural airing of the exit site.

*6.3.6.4 Patient's skin preparation for cannulation*

dialysis session (more information at Section 6.1).

and a third one to secure the needle tubing.

*6.3.6.7 Needle removal and haemostasis (HS)*

*6.3.6.1 Exit site*

*6.3.6.2 Type of dressing*

*6.3.6.3 Patency*

skin preparation.

*6.3.6.5 Cannulation*

*6.3.6.6 Needle taping*

*Vascular Access Management for Haemodialysis: A Value-Based Approach from NephroCare… DOI: http://dx.doi.org/10.5772/intechopen.84987*

#### *6.3.6.1 Exit site*

*Vascular Access Surgery - Tips and Tricks*

treatment.

*6.3.5 AVF/AVG assessment*

agulation therapy.

Palpation (touch and feel):

Auscultation (listen to the fistula):

sound characteristics.

*6.3.6 CVC assessment*

length.

Inspection (observe and look for):

warmth, oedema and rash over the fistula.

cant proximal stenosis in the outflow tract.

decreased blood supply (possible steal syndrome).

evaluated and all treatment parameters should be validated. When using a CVC, the catheter exit site must be examined thoroughly for the presence of any signs of infection. A physical assessment of the VA must be carried out before every

Using the eyes, ears and fingertips, AVF/AVG are assessed for complications.

• Signs and symptoms of inflammation/infection: redness, drainage, abscess,

• Infiltration/haematoma: needle infiltration of new AVF is a relatively frequent complication, and haematoma can develop easily in patients on chronic antico-

• Pseudo-aneurysms are frequently seen on the fistula arm: pseudo-aneurysms develop because of trauma from cannulating the same site or due to a signifi-

• Skin colour: changes in the skin colour could point to stenosis of infection, discoloured or cyanotic fingers could be an early sign of steal syndrome.

• Thrill: normally a very prominent thrill is present at the anastomosis and the fistula is soft and easily compressible, the thrill diminishes evenly along access

• Skin temperature: warmth could be a sign of infection; cold could be a sign of

• Listen for bruit: listen to entire access every treatment and note changes in

AVF/AVG physical examination is crucial to evaluate the proper function and to detect possible signs of complications. If any sign of complication is present, the VA should not be used and the patients should be evaluated by the nephrologist [43].

CVC, despite being considered the worst HD VA, is used in a considerable number of patients, up to 80%, either due to the need to start HD following emergency catheter placement or due to lack of native vessel to create an AVF or place an AVG. The goal of performing a HD treatment via a CVC should be the achievement of the best patient outcome as possible, while keeping all possible complications under control. For this purpose, it is fundamental that all team members are familiar with the principles of CVC care, which include assessment, usage, surveillance and

**42**

maintenance.

The exit site of the CVC must always be inspected at each HD treatment for any signs of irritation, infection or development of allergy to dress or disinfectant solution, including tenderness, skin peeling, rash, swelling, exudate and redness. European Renal Best Practice (ERBP) recommends to always ensure the area being cleansed around the exit site is slightly larger than the final dressing and include the section of the catheter that will be underneath the dressing [147].

#### *6.3.6.2 Type of dressing*

There is a wide variety of different types of products for dressing and securing CVCs, but the superiority of one over another has not yet been demonstrated. According to ERBP, for long-term catheters sterile gauze is preferable, for enabling maximal natural airing of the exit site.

#### *6.3.6.3 Patency*

Before starting the HD treatment, the patency of the catheter should be evaluated. The locking solution use in the previous treatment should be removed by withdrawing 3–5 ml, locking solution mixed with blood. Using a 10 ml syringe filled with 0.9% NaCl, a small amount of blood should be aspirate into the syringe and observed for clots containment. If yes, flush should not be done. If unable to flush the physician should be alerted to assess and, if necessary, provide intervention.

#### *6.3.6.4 Patient's skin preparation for cannulation*

Before needle insertion in an AVF/AVG, proper needle-site preparation should be done to reduce infection rates. Site selection should be done prior to the final skin preparation.

#### *6.3.6.5 Cannulation*

The most important procedure is the cannulation of an AVF/AVG, and over the course of a day, it is carried out on numerous occasions by the dialysis nurse. Choice of the correct cannulation site and technique are fundamental factors for an optimal dialysis session (more information at Section 6.1).

#### *6.3.6.6 Needle taping*

Tape the needle in place on completion of insertion, secure it using a minimum of three strips of tape: one to fix the wings, a second on top of it to secure the needle and a third one to secure the needle tubing.

#### *6.3.6.7 Needle removal and haemostasis (HS)*

The procedure of needle removal by the nurse is as important as the cannulation of the AVF. Needle withdrawal must be done carefully to prevent tearing of the vessel, to minimise access trauma and to achieve optimal HS. The needle should be removed using the same inclination as the insertion angle. Appropriate pressure should be applied after complete needle removal (thrill should be felt above and below the site of pressure). The pressure must be hold for 8–12 min without checking.

#### *6.3.6.8 Haemostasis*

HS of the first cannulation must always be performed by skilled nursing staff, since the vessel wall is fragile and there is an increased risk of haematoma formation. Manual compression applied by the nurse, health care assistant, or patient is the standard of care following withdrawal of HD needles. For the patients who cannot or are unwilling to hold pressure for sufficient time for HS the use of a HS clamp or band is required.

#### *6.3.6.9 Patient education to care for VA*

One of the most important responsibilities of the nurses is patient education. To achieve shared decision making, improve understanding and adherence, motivate, and encourage self-management, effective patient education is crucial [20] (more information at Section 5).

A good knowledge on VA management is necessary to enable the nurse to assess, plan, implement and evaluate the care given to patients before, during and after cannulation (AVF/AVG) or connection (CVC) and to deal with complications. The first use of a VA is an important opportunity for the expert nurse to demonstrate and transfer her/his knowledge and expertise to novice HD nurse. This will ensure the continuing education of healthcare staff engaged in patient care within the HD unit.

### **7. VA future outlook**

As stated in the background section, VA is an essential component of a life-sustaining therapy in ESKD patients with a significant effect on both patient outcomes and associated costs [3, 8]. Therefore, taking a value-based approach and identifying opportunities for VA that would provide the right balance between optimal patient outcomes and total spending would be the ultimate goal [148].

The clinical/medical evidence basis clearly shows from a value-based perspective that it is obvious that native arteriovenous fistula is still the best VA option providing the highest survival expectation and the lowest complication risk [149]. However, patient profiles have become more complex including an increase of comorbidities that affect the success rates of AVF [150]. Therefore, several attempts have been made to substitute failing native AVF by new VA devices including vascular graft (synthetic and biomaterial), implantable devices (graft, venous catheter and port catheter) or hybrid system (graft port or venous port catheter) with limited success [151, 152].

What are the new VA perspectives to improve outcome and/or to expand VA possibilities in difficult cases. Several opportunities are currently under clinical investigation:

First, better management and use of existing VA from installation (VA network mapping) to maintenance permitted by use of non-invasive imaging (US-based) including monitoring technologies (online monitoring HD) [149, 153, 154] or connected technologies offering 24/7 continuous monitoring of VA patency [155]. The idea behind is to facilitate maturation of newly created AVF and/or to intervene earlier on failing VA to permit percutaneous interventional procedures for restoring patency [156].

Second, make better use and improve outcome of tCVC or implanted venous access port devices by implementing strict rules of handling and generalisation of catheter locking solutions [157].

**45**

**8. Conclusion**

*Vascular Access Management for Haemodialysis: A Value-Based Approach from NephroCare…*

sis, to reduce neointimal proliferation leading to stenosis [160–162].

Third, assess clinical value of minimally invasive procedures such as percutane-

Fourth, use medication either with systemic or local action to prevent thrombo-

Fifth, evaluate performance and outcome of bioengineered VA conduit based on vascular matrix formation and autologous cell seeding as part of regenerative

Next to the medical future outlook, the economic perspective should also be considered, reviewing the bottom part of the value-based healthcare equation where value "is defined as the health outcomes achieved per dollar spent" [148]. Two systematic reviews (one focused on VA creation and the other on VA maintenance) identified a total of ~15 economic evaluations and/or cost and resource use analyses. As from a medical perspective, AVF is concluded to be the most cost-effective VA type for HD patients [164]. Nevertheless, the number of studies identified, and the level of evidence currently available shows a clear gap in knowledge to come to a solid conclusion from a health economic point of view. Especially, the total patient life cycle with regards to costs is not clearly mapped including the identification of: downstream costs, costs of adverse events, associated costs of patency rates and long-term consequences in effectiveness of the HD treatment. Finally, there is one additional component that would need to be tackled which

is the health system set up in general around transition management for CKD patients including VA placement and maintenance. According to Porter, healthcare needs to be structured based on meaningful outcomes to patients to maximise the value that is delivered in the end [165]. As part of this structure, episodic treatment should be transferred to bundling therapies under the responsibility of one provider [165]. Translating this to renal care would entail to include VA placement and management in the dialysis reimbursement bundle, which is already the case in, for

The reason for this reorganisation is especially needed as currently approximately 32–73% of the CKD patient population experiences an unplanned start of dialysis [166–169]. This unplanned start leads to the use of the least optimal VA type (CVC) rather than AVF as this requires a 6-month maturity phase. This suboptimal start is caused by a lack of screening and diagnosis of CKD patients in time, as these patients are first seen by a general practitioner (GP) rather than a nephrologist [170]. Hence, awareness/educational measures toward GPs could also be one of the future outlooks from a health policy perspective to improve VA practice and

In conclusion, the outlook for the future for VA practice is promising and has potential to improve significantly from multiple perspectives (medical, economic, health system, etc.). A collaboration and partnership between these disciplines would create an understanding and clear roadmap for next steps to put these into practice.

VA is an essential component of renal replacement therapy in ESKD patients. VA is currently referred to the life line of dialysis-dependent patient. Dialysis access relies on two main options: arteriovenous shunt (autologous AVF and AV graft); veno-venous access (tunnelled catheter and venous port device). AVFs are still the preferred VA option associated with best outcomes, higher performances and lower morbidity. Various innovative and quite interesting options, including minimally invasive percutaneous creation of AVFs and implantation of bioengineered vascular conduit deserve further clinical studies to enter in the VA armamentarium. VA

*DOI: http://dx.doi.org/10.5772/intechopen.84987*

ous creation of VA [158, 159].

example, USA, Portugal and Spain.

consequently the lifecycle of HD patients.

medicine [19, 163].

*Vascular Access Management for Haemodialysis: A Value-Based Approach from NephroCare… DOI: http://dx.doi.org/10.5772/intechopen.84987*

Third, assess clinical value of minimally invasive procedures such as percutaneous creation of VA [158, 159].

Fourth, use medication either with systemic or local action to prevent thrombosis, to reduce neointimal proliferation leading to stenosis [160–162].

Fifth, evaluate performance and outcome of bioengineered VA conduit based on vascular matrix formation and autologous cell seeding as part of regenerative medicine [19, 163].

Next to the medical future outlook, the economic perspective should also be considered, reviewing the bottom part of the value-based healthcare equation where value "is defined as the health outcomes achieved per dollar spent" [148]. Two systematic reviews (one focused on VA creation and the other on VA maintenance) identified a total of ~15 economic evaluations and/or cost and resource use analyses. As from a medical perspective, AVF is concluded to be the most cost-effective VA type for HD patients [164]. Nevertheless, the number of studies identified, and the level of evidence currently available shows a clear gap in knowledge to come to a solid conclusion from a health economic point of view. Especially, the total patient life cycle with regards to costs is not clearly mapped including the identification of: downstream costs, costs of adverse events, associated costs of patency rates and long-term consequences in effectiveness of the HD treatment.

Finally, there is one additional component that would need to be tackled which is the health system set up in general around transition management for CKD patients including VA placement and maintenance. According to Porter, healthcare needs to be structured based on meaningful outcomes to patients to maximise the value that is delivered in the end [165]. As part of this structure, episodic treatment should be transferred to bundling therapies under the responsibility of one provider [165]. Translating this to renal care would entail to include VA placement and management in the dialysis reimbursement bundle, which is already the case in, for example, USA, Portugal and Spain.

The reason for this reorganisation is especially needed as currently approximately 32–73% of the CKD patient population experiences an unplanned start of dialysis [166–169]. This unplanned start leads to the use of the least optimal VA type (CVC) rather than AVF as this requires a 6-month maturity phase. This suboptimal start is caused by a lack of screening and diagnosis of CKD patients in time, as these patients are first seen by a general practitioner (GP) rather than a nephrologist [170]. Hence, awareness/educational measures toward GPs could also be one of the future outlooks from a health policy perspective to improve VA practice and consequently the lifecycle of HD patients.

In conclusion, the outlook for the future for VA practice is promising and has potential to improve significantly from multiple perspectives (medical, economic, health system, etc.). A collaboration and partnership between these disciplines would create an understanding and clear roadmap for next steps to put these into practice.

#### **8. Conclusion**

VA is an essential component of renal replacement therapy in ESKD patients. VA is currently referred to the life line of dialysis-dependent patient. Dialysis access relies on two main options: arteriovenous shunt (autologous AVF and AV graft); veno-venous access (tunnelled catheter and venous port device). AVFs are still the preferred VA option associated with best outcomes, higher performances and lower morbidity. Various innovative and quite interesting options, including minimally invasive percutaneous creation of AVFs and implantation of bioengineered vascular conduit deserve further clinical studies to enter in the VA armamentarium. VA

*Vascular Access Surgery - Tips and Tricks*

HS of the first cannulation must always be performed by skilled nursing staff, since the vessel wall is fragile and there is an increased risk of haematoma formation. Manual compression applied by the nurse, health care assistant, or patient is the standard of care following withdrawal of HD needles. For the patients who cannot or are unwilling to hold pressure for sufficient time for HS the use of a HS

One of the most important responsibilities of the nurses is patient education. To achieve shared decision making, improve understanding and adherence, motivate, and encourage self-management, effective patient education is crucial [20] (more

A good knowledge on VA management is necessary to enable the nurse to assess, plan, implement and evaluate the care given to patients before, during and after cannulation (AVF/AVG) or connection (CVC) and to deal with complications. The first use of a VA is an important opportunity for the expert nurse to demonstrate and transfer her/his knowledge and expertise to novice HD nurse. This will ensure the continuing education of healthcare staff engaged in patient care within the HD

As stated in the background section, VA is an essential component of a life-sustaining therapy in ESKD patients with a significant effect on both patient outcomes and associated costs [3, 8]. Therefore, taking a value-based approach and identifying opportunities for VA that would provide the right balance between optimal

The clinical/medical evidence basis clearly shows from a value-based perspective that it is obvious that native arteriovenous fistula is still the best VA option providing the highest survival expectation and the lowest complication risk [149]. However, patient profiles have become more complex including an increase of comorbidities that affect the success rates of AVF [150]. Therefore, several attempts have been made to substitute failing native AVF by new VA devices including vascular graft (synthetic and biomaterial), implantable devices (graft, venous catheter and port catheter) or hybrid system (graft port or venous port catheter)

What are the new VA perspectives to improve outcome and/or to expand VA possibilities in difficult cases. Several opportunities are currently under clinical

First, better management and use of existing VA from installation (VA network mapping) to maintenance permitted by use of non-invasive imaging (US-based) including monitoring technologies (online monitoring HD) [149, 153, 154] or connected technologies offering 24/7 continuous monitoring of VA patency [155]. The idea behind is to facilitate maturation of newly created AVF and/or to intervene earlier on failing VA to permit percutaneous interventional procedures for restoring

Second, make better use and improve outcome of tCVC or implanted venous access port devices by implementing strict rules of handling and generalisation of

patient outcomes and total spending would be the ultimate goal [148].

*6.3.6.8 Haemostasis*

clamp or band is required.

information at Section 5).

**7. VA future outlook**

with limited success [151, 152].

catheter locking solutions [157].

investigation:

patency [156].

unit.

*6.3.6.9 Patient education to care for VA*

**44**

performance is a key factor to drive success of extracorporeal renal replacement treatment. Furthermore, VA dysfunction and/or morbidity (stenosis, thrombosis and infection) are a source of frequent hospitalisation and corrective procedures. VA management in CKD patient is of tremendous importance in the overall quality care of dialysis patients. VA care and outcome are greatly improved in a large dialysis care provider network by means of a referent VAC and continuous quality improvement program [171].
