Physical Assessment of the Vascular Access

1. Physical Assessment of the Vascular Access Carol Lyden RN, MS, CNN Assistant Director of Quality Improvement IPRO ESRD Network of New York

2. Goal To improve AV Fistula rates and to decrease catheter rates in prevalent hemodialysis patients 2

3. Objectives Discuss the goals of the FF initiative Identify reasons to improve AVF rates and to decrease catheter rates Early identification of vascular access complications through physical examination 3

4. Goals of Fistula First Initiative CMS goal AV fistula rate of 66% in prevalent pts AVF rate of 50% in incident pts Catheters >90 days <10% NW goal – reduce deficit by 20% each year. Baseline – Mar 2010 – 58.3% AVF in Prevalent pt Re-measure - March 31, 2011 – goal 59.8%

5. Facility Goal 5

6. AVF Rates in Prevalent Patients 6

7. Network / National Data February 2011 Data 7

8. Why should we place AVF and reduce Catheters? Patient Outcomes Practice Guidelines KDOQI Renal Physicians Association Regulations Conditions for Coverage Network Reimbursement Hospitalizations and increase morbidity and > mortality risks Increase costs Complications – infection, stenosis, thrombosis, aneurysm and limb ischemiaHospitalizations and increase morbidity and > mortality risks Increase costs Complications – infection, stenosis, thrombosis, aneurysm and limb ischemia

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10. KDOQI Goal: Place AVF Detect dysfunction before thrombosis Focus on usable AVF Guidelines Pt preparation for permanent hemo access Selection & placement of hemo access Cannulation & accessing hemo cath Monitoring, surveillance & diagnostic testing Treatment of complications Clinical Reccommendations

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12. Conditions of Coverage 12

13. Conditions of Coverage 13

14. ESRD Network Contracted by CMS Oversee quality management of dialysis & transplant units Collect data – vascular access, labs, CMS forms Identify & work with low performing facilities Regulations – CfC V772 Relationship with the ESRD Network Dialysis unit act on recommendations from NW Participate in NW activities & pursue NW goals 14

15. Reimbursement Bundling of payment – Jan 2011 Pay-for-performance – Jan 2012 Vascular access type on bills since 7/2010 Catheter, AVG or AVF with 2 needles Access placement 2009 increased reimbursement for placement of AVF to be similar to AVG. 15

16. Physical Assessment Clinical assessment by an experienced dialysis nurse has been shown to be 80% accurate in predicting AVF maturation. 16

17. How to become an expert at access assessment… Learn the Basics Practice Practice Practice

18. What is the most under utilized method of AVF assessment? Physical exam Experienced dialysis nurses have an 80% success rate identifying AVF maturity*

19. Drawing from the Vascular Surgeon

20. Using the tools we have… Eyes Ears Fingertips There is a lot of literature indicating that physical assessment is the best tool for caring for vascular access. This consists of looking, listening and feeling.There is a lot of literature indicating that physical assessment is the best tool for caring for vascular access. This consists of looking, listening and feeling.

21. Look Compare to other extremity Skin Color/Temperature Skin Integrity Edema Poor Wound Healing Drainage Vein Development Accessory Veins Cannulation Areas Aneurysms There are several things you should look for when starting your physical assessment of the vascular access. First you want to compare the access arm to the other extremity – looking for any differences like edema, skin color, circulation, whether the skin is intact or there is any drainage. Also look specifically at the access – what is the size of the vessel, what does the area cannulated look like, is there any aneurysm formation.There are several things you should look for when starting your physical assessment of the vascular access. First you want to compare the access arm to the other extremity – looking for any differences like edema, skin color, circulation, whether the skin is intact or there is any drainage. Also look specifically at the access – what is the size of the vessel, what does the area cannulated look like, is there any aneurysm formation.

22. Look for Complications Redness Drainage Infection Poor Healing Skin Color Central Edema or Small Blue Outflow or Purple Vein Veins Stenosis Hands: - Cold - Painful Steal - Numb Syndrome Fingers: - Discolored - Lesions Cannulation sites: - Over used Use - Under used of Access Aneurysms You want to look for specific complications: infection, clues that there may be stenosis formation, whether or not the patient has steal syndrome, the presence of cannulation site infection or aneurysm formation – is the skin tight and shinny (like a boil ready to pop) or thin-skinned.You want to look for specific complications: infection, clues that there may be stenosis formation, whether or not the patient has steal syndrome, the presence of cannulation site infection or aneurysm formation – is the skin tight and shinny (like a boil ready to pop) or thin-skinned.

23. Listen to the Patient & the AVF/AVG Question the patient about their access Changes Pain Bleeding/Drainage Numbness Temperature Document your findings

24. Listening to the AVF Every nurse educator’s dream – stethoscopes for vascular access assessment!Every nurse educator’s dream – stethoscopes for vascular access assessment!

25. What are we listening for? The Bruit Normal bruit is a continuous, soft, low pitched, swishing sound Is heard along the entire body of the vein or graft. Listen for changes in characteristics: Continuous to Discontinuous Soft low pitched swishing to High pitched or Shrill Absence Listening every treatment allows you to determine patency, quality and continuousness of the sound (the blood flow). It is so important to get baseline information on the access so you will be able to identify changes that will allow us to determine problems, the major one being stenosis. Changes in the characteristics of the bruit would include the choppy, separate sounds referred to as discontinuous sounds. If a stenosis is present, the narrowing may cause the pitch to go up or may be louder at the stenosis than at the anastomosis. You can always determine the direction of flow of the blood. New fistula creation techniques may alter the direction of the blood flow in the arm, so it is really important to know how the venous needle needs to be placed. Placing needles in the wrong direction can cause recirculation and decreased adequacy.Listening every treatment allows you to determine patency, quality and continuousness of the sound (the blood flow). It is so important to get baseline information on the access so you will be able to identify changes that will allow us to determine problems, the major one being stenosis. Changes in the characteristics of the bruit would include the choppy, separate sounds referred to as discontinuous sounds. If a stenosis is present, the narrowing may cause the pitch to go up or may be louder at the stenosis than at the anastomosis. You can always determine the direction of flow of the blood. New fistula creation techniques may alter the direction of the blood flow in the arm, so it is really important to know how the venous needle needs to be placed. Placing needles in the wrong direction can cause recirculation and decreased adequacy.

26. Feel Pulses To assess inflow problems, the character of the radial and brachial pulses should be assessed. Markedly decreased or absent arterial pulse is indicative of potential access failure. Temperature Warmth = possible infection Cold = decreased blood supply Thrill Should be present at the anastomosis Normally present in both systole and early diastole Diminishes as you move up from the anastomosis Thrill can be felt at the site of a stenosis Typically, our patients have lower body temperatures, so when we feel warmth, it may indicate a possible infection. Now it is important to have at least one other sign or symptom – a temperature, redness, drainage, tenderness. Cold could indicate a decreased blood supply. You need to compare the temperature with the other limb. Sometimes the coldness is created by diverting too much away from the hand – this is called Steal Syndrome The thrill should be identified before each cannulation. If you cannot feel the thrill, you need to confirm with a stethoscope the presence of a bruit. If there are no sounds at all, do not cannulate the access and notify the physician. As you are feeling the entire length of the access and you come across a flat spot, feel for a thrill – this would indicate that there is a stenosis.Typically, our patients have lower body temperatures, so when we feel warmth, it may indicate a possible infection. Now it is important to have at least one other sign or symptom – a temperature, redness, drainage, tenderness. Cold could indicate a decreased blood supply. You need to compare the temperature with the other limb. Sometimes the coldness is created by diverting too much away from the hand – this is called Steal Syndrome The thrill should be identified before each cannulation. If you cannot feel the thrill, you need to confirm with a stethoscope the presence of a bruit. If there are no sounds at all, do not cannulate the access and notify the physician. As you are feeling the entire length of the access and you come across a flat spot, feel for a thrill – this would indicate that there is a stenosis.

27. Feel Venous Assessment Feel the entire length of the vein Vein should be soft and pliable Elevating the arm above the heart should result in at least partial collapse of the vein. Assess vein diameter and compare to previous findings Evaluate existing and new cannulation site options Check for flat spots – over a stenosis you can feel its thrill Feel for accessory veins As you are feeling the entire length of the access and you come across a flat spot, feel for a thrill – this would indicate that there is a stenosis. As you are feeling the entire length of the access and you come across a flat spot, feel for a thrill – this would indicate that there is a stenosis.

28. Clinical Signs Changes in characteristics of bruit Changes in characteristics of thrill Venous pressure increasing Negative Arterial pressure elevating Strong flashback of blood upon cannulation Problems cannulating Increased bleeding with cannulation and/or post treatment Unexplained decrease in adequacy 28

29. Juxta-Anastomotic Stenosis Development of a stenosis in the first 3–4 cm. from the anastomosis is called juxta-anastomotic stenosis (JAS) and is a serious problem in early development of the new AVF. In flow restriction caused by this stenosis is one of the most frequent causes of early AVF failure. Main predictive factors in early fistula failure are female gender,diabetes melllitus and surgical expertise. Because diabetic patients have more pronounced arterial calcification at the wrist than at the elbow, selection of a more proximal site may be a better option for these patients. This lesion can be associated with surgical trauma in the creation of the fistula, but the change in hemodynamic flow velocity from the artery into the vein can result in this occurring even following a perfect surgical procedure.

30. Proximal Stenosis Stenosis in the proximal vein are more prevalent in mature AVF. Creates resistance that results in a more forceful pulse As the stenosis becomes more developed, a more robust or “water hammer” pulse will be felt. There may be a palpable thrill over the site of the stenosis. The vein is pulsatile and firm and fails to collapse when the arm is elevated above the heart. On ausculation the bruit will be high pitched and heard only during systole.

31. Low Tech Fistulogram

32. Accessory Veins May contribute to early failure of AVF Divert blood flow from the main vein and reduce pressure potentially delaying the maturation of the fistula. More common with vein side-to-side artery anastomosis than the more common vein end- to-side artery anastomosis.

33. Assessing for Accessory Veins Begin with a visual inspection for obvious accessory veins. Manually occlude the fistula just above the anastamosis. This stops the flow through the fistula and the thrill at the anastamosis should cease. Slowly move the occlusion point up the fistula, feeling for the thrill at the anastamosis. If the thrill re-appears it is because an accessory vein is providing an outflow channel. All accesory veins are not bad. Some may develop into usable cannulation sites. Ligation of accessory veins is up to the physician.

34. When is an AVF mature? Soft firm and thin thick wall Diameter of vessel increasing (2mm ?? 4mm) No collaterals detracting form the main conduit Able to visualize and feel sites appropriate for cannulation At one to two weeks post-op, you should be able to see an increase in the diameter of the fistula. The vein initially will feel soft and mushy and as the diameter increases, the walls should start to toughen up and become more firm to the touch. We typically want to see the diameter double in size, and recent studies on vessel mapping indicate that the vessel should be at least 2 mm in diameter. New research indicates that experienced dialysis nurses have an 80% success rate at identifying AVF maturity. If you do not see any changes within four weeks, the access will not develop either as a result of an inflow stenosis or the presence of accessory veins. At one to two weeks post-op, you should be able to see an increase in the diameter of the fistula. The vein initially will feel soft and mushy and as the diameter increases, the walls should start to toughen up and become more firm to the touch. We typically want to see the diameter double in size, and recent studies on vessel mapping indicate that the vessel should be at least 2 mm in diameter. New research indicates that experienced dialysis nurses have an 80% success rate at identifying AVF maturity. If you do not see any changes within four weeks, the access will not develop either as a result of an inflow stenosis or the presence of accessory veins.

35. When do we decide it’s not maturing? Generally speaking, at 4 weeks post AVF creation, if there is no measurable increase in vein diameter and the vessels are not becoming more defined and the walls thickening, the patient should be referred back to the surgeon for evaluation

36. Would you cannulate this AVF? No, this fistula is not developed enough – the diameter of the vessel is near the bore size of the needle.No, this fistula is not developed enough – the diameter of the vessel is near the bore size of the needle.

37. For More Information Contact: Carol Lyden (516) 209-5302 clyden@nw2.esrd.net 37