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Guidelines for Venous Access in Patients with Chronic Kidney Disease

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Guidelines for Venous Access in Patients with Chronic Kidney Disease Guidelines for Venous Access in Patients with Chronic Kidney Disease A Position Statement from the American Society of Diagnostic and Interventional Nephrology1 Clinical Practice Committee and the Association for Vascular Access2 Jeffrey Hoggard,* Theodore Saad,† Don Schon,‡ Thomas M. Vesely,§ and Tim Royer– *Eastern Nephrology Associates, P.L.L.C., Greenville, North Carolina, †Nephrology Associates, P.A., Department of Medicine, Nephrology Christiana Care Health System, Newark, Delaware, ‡Arizona Kidney Disease and Hypertension Surgery Center, Phoenix, Arizona, §Vascular Access Center, Frontenac, Missouri, and ¶VA Puget Sound Health Care System, Seattle, Washington ABSTRACT At the time of hemodialysis vascular access evaluation, many greater prevalence of arteriovenous fistulae in the US hemodi- chronic kidney disease patients already have iatrogenic injury alysis population will require identification of those patients to their veins which impedes the surgical construction of an prior to reaching end-stage renal disease and an educational arteriovenous fistula (AVF). Achieving the important goal of a and procedural system for preserving their veins. The use of venous access devices is ubiquitous in mod- the future. Secondly, these guidelines provide an algo- ern medicine. Establishing and maintaining intravenous rithm for delivery of optimal venous access in these access for patients with chronic kidney disease (CKD) high-risk patients. Ultimately, this requires an integrated necessitate special considerations unique to this patient team approach involving the physician requesting population. In patients with CKD preservation of the venous access, the nurses caring for the patient, the vas- integrity of peripheral and central veins is of vital impor- cular access nurses responsible for placement of periph- tance for future hemodialysis access. Cannulation of eral venous access, vascular access experts responsible veinsandinsertionofvenousaccessdeviceshavepoten- for image-directed placement of venous access (interven- tial to injure the veins and thereby incite phlebitis, sclero- tional radiologists, nephrologists, or surgeons), the clini- sis, stenosis or thrombosis. The creation of a high cal nephrologist managing the patient’s CKD, and the quality arteriovenous fistula (AVF) may become diffi- vascular surgeon responsible for creating arteriovenous cult or impossible in the presence of prior venous injury. hemodialysis accesses. Optimal venous access practice The purpose of these guidelines is twofold. First, they and management for the CKD patient is likely best provide criteria for early identification of CKD patients achieved by establishing consensus Policy and Procedure who are likely to need a hemodialysis graft or fistula in at each institution. 1ASDIN Clinical Practice Committee members: Steve Ash, M.D.,Chair,GeraldBeathard,M.D.,JeffreyHoggard,M.D., Background Terry Litchfield, M.P.A., Dr.PH., George Nassar, M.D., Tony Samaha, M.D., Don Schon, M.D., Vijay Sreenarasimhaiah, Vascular Access for Hemodialysis M.D.,TomVesely,M.D.,MonnieWasse,M.D. 2 The autogenous AVF is the preferred form of vascu- AVA members: Denise Macklin, RNBC, Kathy McHugh, RN, lar access for hemodialysis, delivering superior patency BSN,TimRoyer,BSN,CRNI,KelliRosenthal,MS,RN,BC,CRNI, ANP, APRN, BC with lower morbidity, hospitalization, and costs relative to prosthetic grafts or hemodialysis catheters (1–6). For Address correspondence to: Jeffrey Hoggard, MD, 1776 these reasons, the nephrology community has imple- Blue Banks Farm Rd, Greenville, NC 27834, or email: jhog- [email protected]. mented a nationwide agenda to increase the creation of Seminars in Dialysis—Vol 21, No 2 (March–April) 2008 autogenous fistulae in hemodialysis patients. The pp. 186–191 National Kidney Foundation – Kidney Disease Out- DOI: 10.1111/j.1525-139X.2008.00421.x comes Quality Initiative (NKF-KDOQI) publishes 186 GUIDELINES FOR VENOUS ACCESS IN PATIENTS 187 specific guidelines relative to creation and management ing thrombosis after PICC placement. In a similar study, of hemodialysis vascular accesses (7). More recently, the Gonsalves et al. reviewed venographic studies that were Centers for Medicare and Medicaid Services (CMS) performed both before and after insertion of PICCs in along with the regional End-Stage Renal Disease 150 patients to determine the incidence of central venous (ESRD) Networks and the clinical nephrology commu- stenosis or occlusion (17). These investigators reported nity have developed and promoted the National Vascu- that 7.5% of patients with previously normal central lar Access Improvement Initiative (NVAII) called venograms developed subsequent venographic abnor- ‘‘Fistula First Breakthrough,’’ with the specific goal of malities after PICC placement; 4.8% developed central promoting more autogenous fistulae in hemodialysis venous stenosis and 2.7% had central venous occlusion. patients. By 2009, the goal is to achieve a 67% Abdullah et al performed venography at the time of prevalence rate of autogenous fistulae in hemodialysis PICC removal in a small prospective study and docu- patients (8). Ultimately, this strategy to create more mented venous occlusion in 38.5% of 26 patients (18). functional fistulae is critically dependent on the avail- Central venous catheters inserted into the subclavian ability and condition of the patient’s central and vein can cause stenosis and thrombosis. Hernandez et al. peripheral veins. Frequent venipuncture and the indis- used serial venographic studies to evaluate the long-term criminate use of peripheral intravenous lines, peripher- effects of subclavian vein catheters in 42 patients (19). At ally inserted central catheters (PICCs) or central venous the time of catheter removal, 45% of patients had ste- catheters can damage veins, impair venous circulation noses and 7% had total thrombosis of the subclavian and jeopardize future fistula construction or function. vein. In a retrospective study of 279 central venous cath- Therefore, to preserve peripheral and central veins for eters in 238 patients, Trerotola et al. reported that cathe- future hemodialysis vascular access it is of paramount ter-related venous thrombosis occurred in 13% of importance that CKD patients achieve early protection patients with subclavian vein catheters, compared with of their critical venous real estate. This important con- 3% of patients with internal jugular vein catheters (20). cept has been emphasized in editorials by Trerotola (9), The mean time to thrombosis was 36 days for subcla- Saad and Vesely (10), and more recently by McLennan vian catheters and 142 days for internal jugular vein (11). catheters. Similarly, Bambauer reported an incidence of thrombosis or stenosis in 8% of patients receiving sub- clavian vein catheters and only 0.3% of patients with Venous Injury internal jugular vein catheters (21). The NKF-KDOQI The injurious effects of phlebotomy and peripheral Guidelines recommend the use of internal jugular vein and central venous catheters include phlebitis, venous and avoidance of the subclavian vein and PICCs for sclerosis, stenosis, and thrombosis. Vascular damage venous access based on this data. may occur early, at the time of catheter insertion, or the injury may be progressive if the catheter remains in the Guidelines for Venous Access in Patients with veinforanextendedperiodoftime(12).Forauerand Chronic Kidney Disease colleagues reported their findings from an autopsy study; these investigators described pathological changes of endothelial denudation associated with short-term A. Identify CKD patients who may need hemodialy- central catheter use. With long-term catheter use, there sis treatment in the future. was vein wall thickening, increased number of smooth 1. Patients with CKD Stages-3, 4 or 5. This muscle cells, and focal catheter attachments to the vein includes stage 5 CKD patients currently receiv- wall with thrombus and collagen (13). Ducatman et al ing hemodialysis or peritoneal dialysis. performed an autopsy study of 141 patients with central 2. Patients with a functional kidney transplant. venous catheters and reported that 32% had pericathe- B. Venous Access for stage 3–5 CKD patients. ter thrombus in the brachiocephalic veins or superior 1. The dorsal veins of the hand are the preferred vena cava within 2 weeks after catheter insertion (14). In location for phlebotomy and peripheral venous the majority of previously published studies, including access. the classic study of PICCs by Grove and Pevec, follow- 2. The internal jugular veins are the preferred up imaging studies were only performed in symptomatic location for central venous access. patients (15). A more accurate assessment of venous 3. The external jugular veins are an acceptable injury would require thorough venographic imaging alternative for venous access. both before and after placement of the venous catheters 4. The subclavian veins should not be used for cen- in all patients. Allen et al. used contrast venography at tral venous access. the time of initial PICC placement, and then again when 5. Placement of a PICC should be avoided. a subsequent PICC was placed in the same patients (16). C. Implementation of Policy and Procedure for These investigators reported that 23.3% of patients Venous Access in CKD patients. developed venous thrombosis after initial PICC place- ment. When all subsequent PICC placements were included for patients who underwent multiple PICC Policy and Procedure should be established to allow insertion procedures,
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