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Vascular Access Surveillance


Literature review


Vascular access has been an issue of contention amongst different specialist and doctors. Some feel that monitoring and surveillance is not important while others affirm that monitoring is paramount for effective treatment. According to Davies 2007, vascular access is the process of creating a surgical incision to ensure that Haemodialysis is taking place efficiently. There are different methods that are used in the vascular access and each type depends highly on individual characteristics. The arteriovenous fistula the main method of vascular access and it mainly relies on the individual features and characteristics. Vascular access goes hand in hand with surveillance and monitoring and for effective vascular access to take place (Jindal, 2011). Additionally, Brouwer, 2005 affirms that the main purpose of carrying vascular access practices and surveillance is ensuring that haemodialysis process takes place efficiently and effectively hence helping the affected patients (p.48).

Vascular access surveillance and monitoring involves checking the blood flow rate ( BFR), kt/V delivery, the arterial and venous pressure among other characteristics that are pivotal in ensuring that the blood is flowing in the system as it ought. Moreover, it helps in increasing the lifespan of the arteriovenous fistula since prospective intervention and monitoring helps in reducing the number of inpatients days that the patient requires to be in the hospital due vascular related complications (Jidal 2011, p.54). Surveillance is paramount in vascular access since it helps in determine the type of vascular access that the patient will receive hence achieving the ultimatum goal that is curing the patient. Vascular access is usually the main lifeline of patients who are suffering from kidney diseases. Monitoring and surveillance of the arteriovenous fistula is paramount for each patient who is suffering from dialysis.

The evolution of the vascular access has come a long way since the days of Scribner Shunt. Arteriovenous fistula has been recognized as the main process through which dialysis takes place since it is effective and efficient in the end. Many patients who have kidney complications have opted for arteriovenous fistula since it is effective and easy to maintain. In as much as that arteriovenous fistula are highly used by people today, its paramount to note that there are complications such as infection, stenosis, thrombosis among other complications that have plagued the process of treatment. Failure of vascular access has economic and the adequacy of dialysis and in the delivery implications. The measures that are taken for the optimization of the vascular access normally consumes about 8% of the total Medicare spending on the end stage of the renal disease(ESRD).However, there is evidence on evaluating and treating the factors affecting vascular access and function is not taken at the best point. The complications that normally affect the entire dialysis using arteriovenous fistula include the rate of flow blood and loss of patency that are noted in the dialysis units.

The dialysis outcome quality initiative guideline that is also known as(DOQI) that is published by the kidney foundation has went ahead and has provided techniques that could be applied in surveillance and monitoring of the vascular access. Medicare centre and the Medicaid services has authorized surveillance and monitoring to be part of ESRD to ensure that complications are intervened at an early stage. The various techniques have been used for this particular purpose and no clear consensus has been reached concerning the optimal surveillance technique that identifies all the types of accesses. The monitoring strategies that are involved in the monitoring exercise include; palpation, inspection and finally auscultation of the vascular access in attempt to detect any physical signs that may tend to suggest any presence of pathology. Physical extermination of the access by experienced individuals has gone ahead and have adopted specificity and high sensitivity which are crucial in the monitoring.

Authors affirm that vascular surveillance is paramount in each and step of vascular access, which ushers in Haemodialysis. Haemodialyis is an artificial used in the process of achieving the extracorporeal removal of the waste products such as creatinine urea, excess water among other waste products from the blood when kidneys are not functioning due to renal failure. Haemodialysis is among the best forms of treatment that are associated with renal failure. The other two forms of treatment that is used doctors include renal transplant and peritoneal dialysis that are risky and expensive in the end (Davies & Gibbons 2007). Another alternative method that is mainly applicable in extracorporeal separation is the separation of blood components such as the plasma and the aphaeresis. Normally, haemodialysis is mainly arterial venous fistula that is used in inpatient and outpatient therapy where patients visit the hospital occasionally or they are admitted to the hospital for a specific purpose (p.55). The routine haemodialysis is normally conducted in the dialysis of the outpatient facilities where a rooms are built for that specific purpose or even at times one may carry out that action in the hospital where the entire location is modified for that particular purpose. However, in rare circumstances, one may find that haemodialysis being conducted at home whereby technicians and other specialized nurses are ferried to the destined home. However, (Davies & Gibbons 2007) affirms that vascular access surveillance remains crucial whether haemodialysis is taking place in the hospital or in the home setting. its paramount to note that whenever , the process is taking place, complications may arise such as clotting and therefore, it’s important to always set aside a specialist watching over, incase such complications may arise(p.56).

The ideal vascular access surveillance normally provides effective and safe therapy that enables removal and returning of the blood through the extracorporeal circuit. Vascular access is easy and reliable and minimal risks are noted to those who are receiving the haemodialysis (Davies & Gibbons 2007, P.61). Deaver 2010 affirms that vascular access that is monitored and surveyed effectively will ensure that any complications that may arise are catered for and this will not only lead to efficiency, but also it will also promote the well being of the patient. Among the complication that arises during the vascular access is clotting, reduced blood pressure and even cases of bacterial infection. However, with efficient monitoring, it is possible to overcome such challenges and finally enhance effective treatment. The most common and ideal vascular access should be able to provide effective and safe therapy hence enabling effective removal and return of the blood in the extracorporeal circuit. However, effective vascular access and subsequent treatment cannot be achieved without effective monitoring and surveillance. (p.78).

Haemodialysis and vascular access surveillance

When one is starting the haemodialysis treatment, it is crucial to work with the health care team for several months before to ensure that whatever is going to take place would positively influence the treatment process. The most important step before starting the regular haemodialysis session is preparing the vascular access (the point of blood transference) .The vascular access allows transfer and exchange of blood hence making cleansing of the blood possible. Vascular access operation should take place normally a few weeks or months before the actual haemodialysis as it helps in familiarization of the body and detecting any complications that may arise during the entire process. The Early preparation of the vascular access also helps in easier and efficient removal and replacement of the blood with fewer complications hence making the entire treatment process easier and convenient. Surveillance and monitoring of the vascular access is crucial in every stage of vascular access preparation (Jindal 2011, p.34).

There are three types of vascular access for the haemodialysis, which include the arteriovenous fistula (AVF), and the arteriovenous graft, and the arteriovenous catheter. The above methods are used in enhancing haemodialysis and they work differently though their surveillance is paramount. The arteriovenous graft is created through connecting a vein to the artery using soft plastic tubes. After healing of the graft haemodialysis is usually performed through placing two needles in the arterial graft and the next one in the vein graft. The graft normally allows increased flow of blood and mostly the grafts tends to need appropriate attention and upkeep in the end. Tending the graft in the right way ensures that everything is smooth and effective and this promotes the welfare of the patient. Surveillance of the vascular access remains pivotal since it is crucial in preventing and deterring any infections that may arise in the end (Kokotis 2001, p.78).it’s worth noting that most of the arteriovenous grafts fail due to some irreversible thrombosis that cause permanent damage to the grafts. Surveillance is paramount for it enhances early detection hence countering the complication. However, research shows that the surveillance tests do not have significant impact on graft thrombosis especially in the absence of preemptive angioplasty (p.80).

Various non-invasive methods might be applied in an attempt to detect the hemodynamic graft stenosis that has high and positive value of prediction. The tests that are involved include the clinical monitoring and the surveillance through the static dialysis. The duplex ultrasound and flow monitoring of the blood in the graft are also monitored in the exercise. Researchers dispute that there is no available surveillance test that can be used to distinguish a stenosed graft that has probabilities of clotting and those that will remain patent without intervention. As a result, program that deals with graft intervention may result in unnecessary angioplasties. Additionally, there is a substantial proportion of the graft with thromboses despite the fact that there is a normal antecedent surveillance of the tests. There are numerous observational conclusions that have postulated some impressive reduction of the graft thrombosis immediately after the implementation of the stenosis program of surveillance (Yoo 2010, p.191).

Five of the six clinical trials that were carried out did not show reduction of the thrombosis patients who had undergone graft surveillance compared to those who had gone through clinical monitoring. This shows that surveillance is not highly recommendable and successful due to the recurrence of angioplasty and stenosis. In attempt to reduce the graft and fistula, related thrombisis the program should fulfill the criteria hence becoming paramount in the process. First, the test should have high and positive predicative value for the hemodynamic and significant fistula stenosis or the grafts. Secondly, it should be in a position to distinguish between the stenosed accesses that are destined to the thrombose and that normally remain patent without any intervention. Third, the preemptive angioplasty of the stenosis should be detected by the surveillance and ultimately reduce the likelihood of the thrombosis. Research posits that the majority of the grafts tend to fail due to cases irreversible thrombosis that normally damages the grafts permanently (Renal Resource Centre 2009, p.78).

The failure of the graft permanently is attributed to thrombosis that is mostly preceded by easy and controllable episodes of thrombosis. During thrombectomy, angiography normally reveals the underlying hemodynamic and significant stenosis mostly at the venous anastomosis in the draining of the vein or the central vein. The less common stenosis is normally present within the graft or even at the arterial anastomisis. The anatomic cause is mainly detected in levels of around 90% of the thrombosed grafts hence suggesting that stenos is always a prerequisite for the thrombosis in the grafts. It is paramount to note that not all stenosed grafts are destined to clot and clotting highly depends on the individual anatomy. A study of 32 patients who had less than 50% stenosis in attempt to ascertain whether stenosis was attributed to the formation of thrombosis. The patients were later evaluated after three months without intervention, only 23% of them had thrombosis proving that intervention, and surveillance is not crucial in preventing thrombosis. The targeted interventions may also be very crucial in the grafts in improving the long-term access of the outcome (Ronco& Greca 2002,p.45).

Fistula that is normally used in haemodialysis characterizes a direct connection of the vein and artery and once the fistula is created, it becomes a natural part of the body. It is the preferred type of access since upon maturity it becomes a better and stronger hence providing an access point that can flow and last for many decades. After creating the fistula through surgically, it can take weeks or even months before it can be used for treatment. People who suffer from kidney diseases may do several exercises such as squeezing rubber balls to strengthen the fistula even before it is used. In the process dialysis, a catheter is normally inserted in a large vein through either the neck or chest. It is usually a short-term option though in some cases it may be used as a permanent access point (Macklin et al 2003, p.10).

In most cases of dialysis using the catheter, a cuff is normally placed under the skin in attempt to hold the catheter in its appropriate place. The blood flow rate from the catheter to the dialyzer may not be very fast compared to the AV graft or the AV fistula and therefore, it is not advisable to keep on using the catheter. The low speed of the blood may not be very effective n the process of dialysis and therefore making the entire treatment sufficient index to be low compared to the other types of treatments. The higher the speed of the blood ensures that it is cleaned thoroughly hence making the entire process of dialysis effective and efficient in the end. Catheters are likely to be infected now and then since the device is placed inside and outside the body. catheters must be always be kept clean and safe and through that it is possible to overcome any infection that may culminate from such infections. Swimming or bathing are highly restricted for those who have the catheters. Moreover, during dressing, one may disturb the catheter and therefore, cautious is paramount in such a case (Macklin et al, p.2003).

According to NKF (National Kidney Foundation), the fistula is the gold standard access and the centers for Medicare and the Medicaid services (CMS) among other services agree that fistulas are among the best types of vascular access compared to the other types of treatments. In fistula, there are always low rates of complications such as clotting and all these all contribute to the fistula reputation hence the term gold standard. The surveillance and efficient watching have enabled the researchers to acknowledge that fistula to be the best option is haemodialysis. The fistula is commonly referred to as the gold standard since it has lower risks of infection compared to the catheters or the grafts (Renal Resource Centre 2009 p.34).

Moreover, it has a lower tendency of clotting compared to the other grafts and catheters hence proving to be the best form of grafting. Fistula allows greater flow of blood, this increases the entire effectiveness and efficiency of the haemodialysis process, and it reduces the time taken to treat the patients. Fistulas are known to last for a very long time compared to other forms of treatments and they are believed that they can last for longer times and decades. In terms of cost, the fistula are less expensive and they can be easily be maintained compared to the synthetic accesses. The AV fistula is the preferred access although they are also some people who are unable to have the fistula. Compromising the vascular system greatly, the fistula preparation may not be attempted hence causing confusion in the end (Ronco, & Greca 2002,p.34).

Research shows that some people have tried to have fistula surgically created but the process has not been successful and the fistula never matures and therefore, it could not be used. This follows some drawbacks that needs to be addressed and include, prolonged time to mature and sometimes they never mature at all. Moreover, a bulge is formed at the access point and this makes people to feel unattractive hence discouraging many people from having the fistula.

The centre for Medicare and the Medicaid (CMS) and other members of the renal community have always come together to start the first fistula initiative (National Vascular Access improvement initiative) whereby the number of patients of patients with fistula can be expanded as opposed to the other forms of treatment such as grafts and catheters. A researcher and doctor by the name Lawrence Spergel who is an expert in ERSD affirms that when he entered the practice in mid 1970, there were less than 10,000 end stage renal disease (ESRD) patients who were receiving effective haemodialysis(Smith 2010,p.11). He told the Institute for Health Improvement that the number has continued to increase to around 300,000 patients who can access and receive the treatment efficiently. In each community, there are always patients whose lives totally depend on the dialysis and this highly depends on a well functioning vascular access. The ESRD population will continue to grow because more of these are likely to longer and stronger. However, it is worth noting that for haemodialysis parents to live longer and productive lives, optimal vascular is highly required and recommended (Smith 2010, p.11). According to the Fistula first, people with other access types are also good candidates of fistulas. Studies have continued to show that patients who have exhausted the permanent access sites are likely to be re-evaluated and they may undergo the vessel mapping and at least two thirds of the total are found to be the candidates of the AV fistula. Up to today, the initiative has continued to reach its goal of about 40% of the prevalent patients who have fistula. Moreover, by year 2010, the bar has continued to rise whereby 50% of all the new people have accesses fistula and 66% of the total population have used fistula for haemodialysis. It is important to note that fistula care should be taken into account when handling patients who have the surgical fistula since they can expose people to infection. For instance, cleanliness is one of the ways in which one can ensure that the patients are safe (Terumo, 2009)

Cleanliness ensures that the fistula is not infected and through that, it is possible to overcome any challenges that are associated with infection when appropriate cleaning measures are taken into account. Keeping an eye for any infection that may arise is paramount keeping the fistula uninfected will always ensure that the treatment is taking place without much ado. The infections in the fistula can be detected whenever there is a swelling, pain, tenderness or even redness around that particular area. Moreover, if cases of fever arise in a patient who have fistula, it is good to seek help from a professional doctor to reduce chances of further infection and ultimately complication. Cases of restricted blood flow ma y also cause clotting and this may hinder the process of haemodialysis. In attempt to avoid such cases, precautions should be done to ensure that everything is running smoothly (Tordoir 2009, p.45).

Tight clothing should be avoided at all costs since it may restrict free flow of blood hence making treatment a problem in case a clot develops at that point. Moreover, it is not advisable to carry heavy bags or other materials near the era where the fistula since it will cause problems when it comes to clotting. Daily checking of the pulse rate on daily basis is also paramount since it allows one to know the irregularities that may be associated with the blood pressure. Cases of vibration through the arm are known as a thrill and it should be checked several times a day to ensure that everything is smooth and effective. The usage of the needle on the fistula also counts a lot and should ensure that it is used effectively and efficiently to ensure that all is well (Yoo 2010, p.191).

In conclusion, it is evident that vascular access surveillance is paramount since it helps detecting any changes and infections that may occur when one is undergoing the Haemodialyis treatment. Surveillance and monitoring does not only promote efficiency and effectiveness of the treatment process, it also promotes how people recover from the sicknesses. Among the three forms of vascular access are; the arteriovenous fistula, arteriovenous graft and finally the arteriovenous catheter, surveillance has proved to be effective in monitoring the following aspects, thrombosis, rate of blood flow and eventually the infections obtained in bacteria and other pathogens. Surveillance has helped in enhancing patients to live according to the set standards and eventually becoming part of the vascular access program.


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