ORLANDO – Placing an access in a dialysis patient is the beginning of a long road. How do you maintain strong blood flow? How do you prevent thrombosis? What do you need to do to make sure it is “built to last”?
A key to that success, says Gregg Miller, MD, vice present of operations and chief medical officer at Fresenius Vascular Care, is monitoring and surveillance of the access. In his talk, “Make it last forever: Vascular access placement and complications,” presented at the American Nephrology Nurses’ Association’s 46th annual symposium, Miller urged attendees to make it an every-visit task to check the access. “How often should you be monitoring the access?” he queried the audience. “Every day.”
He suggested monthly surveillance, whether it was via Transonic ultrasound review or using Vasc-Alert’s monitoring system—two common surveillance tools available to dialysis staff— may not be enough to keep the access healthy. “If there is one take-home message about access surveillance and monitoring, it is that the more frequently you do it, the better outcomes you will have.”
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Tracking dialysis access complications
In the early days of the Fistula First Breakthrough Initiative, a Medicare—driven program created to encourage increased use of arteriovenous fistulas, dialysis staff were seeing a lot of poorly maturing accesses. But the intent—keeping catheters to a minimum—was on target. “Each time a catheter goes in, it poses more risk” for the patient, Miller said.
And reducing the length of time a catheter is in place can be done. He cited a study done by Fresenius Medical Care clinics in Miami aimed at reducing the 140-period that patients, on average, were dialyzing with a temporary catheter. They set up a protocol to track catheters every two weeks, making sure there was progress in getting a permanent access in place and getting the catheter removed. The result? They dropped 100 days off the average.
“Imagine across a population of patients you could change time with a catheter from 140 days to 40 days,” he said.
Dealing with emergent dialysis patients
Using a temporary hemodialysis catheter doesn’t have to be the only access choice when a patient gets their first dialysis in an emergency room. Fast-access grafts are available and should be considered, said Miller, along with rapid start peritoneal dialysis.
“Patients discharged without a working (non-catheter) access is a big problem.”
Ultimately, quality care includes having a long-term solution to the vascular access, noted Miller. It is a key part of an effective dialysis prescription.