Hamid Ahmadian. Hemodialysis,CRRT,PEX&PAP Nurse
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2 Hamid Ahmadian Hemodialysis,CRRT,PEX&PAP Nurse
3 NURSING CARE IN TEMPORARY AND PERMANENT VASCULAR ACCESS 3
4 انواع دسترسی عروقی 1.Avf (Arterial Venus Fistulla) 2.Cortex 3.Graft 4.Catheter Temporary Continual 4
5 Blood Access Vessel Access periferal vein arterio-venous fistula central-venous access V. jugularis interna V. subclavia V. cubitalis V. femoralis Cimino Fistula 5
6 ویژگی هایAccess 1. کمترین عوارض 4.قابلیت نصب آسان 3.طول عمر باال 2.جریان خون مناسب 6
7 Types of Access 1. A-V fistula 2. Vascular graft: higher complication rates, shorter functional lifes. 3. Tunnel-cuffed catheters; Hickman, Quinton 7 حمید احمدیان کارشناس همو دیالیز
8 Vascular Access Complications Thrombosis and Stenosis of Access: Most common complication Loss of bruit and thrill Stenosis / thrombosis: not Emergencies= tx w/in 24 hours. 8 حمید احمدیان کارشناس همو دیالیز
9 Vascular Access Infections 2-5% of fistulas, 10% of grafts Often signs of sepsis, fever, Hypotension,.... WBC Erythema, swelling, discharge at site often missing. Staph Aureus #1, gram neg #2 Vanc is drug of choice, usually add Gent. 9 حمید احمدیان کارشناس همو دیالیز
10 BLEEDING Hemorrhage: Aneurysm, anastomosis rupture or over anticoagulation. Direct pressure TREATMENT Protamine mg or 0.01 mg/unit hep. Consult surgery or nephrology 10 حمید احمدیان کارشناس همو دیالیز
11 Vascular access aneurysms جایگاه سوزن زدن Repeated punctures Bulging in wall نیاز به سونوگرافی داپلر رنگی Rarely rupture True aneurysms very rare; 4% of fistulas 11 حمید احمدیان کارشناس همو دیالیز
12 HEMODIALYSIS ACCESS OPTIONS 12 حمید احمدیان کارشناس همو دیالیز
13 Fistulas are not as good as you ve been told, and Grafts are not as bad 13 حمید احمدیان کارشناس همو دیالیز
14 Advantages of Arteriovenous Fistulas Longevity - fistulas last longer than grafts Durability - fewer complications - fewer reparative procedures Lower Costs 14 حمید احمدیان کارشناس همو دیالیز
15 PTFE (PolytetraFluoroethylene) Graft angioplasty angioplasty angioplasty Fistula angioplasty 15 حمید احمدیان کارشناس همو دیالیز
16 New Access by Type 2006 US Renal Data System Fistula Graft Catheter 16 حمید احمدیان کارشناس همو دیالیز
17 محل های نصب کاتتر: 1.jugular Vein 2.Femoral Vein 3.Subclavian Vein حمید احمدیان کارشناس همو 17 دیالیز
18 نصب آسان New Catheter Blood Flow 300ml Few Recerculat Flexibility Long Term (15-45 Day) Infection نصب آسان استفاده فوری Old Catheter Blood Flow 200ml High Recerculate Flexibility Mid Term (21 Day) Infection عدم استفاده تا 24 ساعت حمید احمدیان کارشناس همو دیالیز 18
19 دالیل عدم نصب Subclavian Catheter ریه Rubture تماس مکرر با دیواره ورید انحناء 19 حمید احمدیان کارشناس همو دیالیز
20 20 Traditional Hemodialysis Catheters
21 برش داخلی کاتتر 21
22 22 NEW CATHETER
23 محل های نصب کاتتر و مزایا و مشکالت Disadvantage Advantage تعبیه آسانتر احتمال خونریزی کمتر خطرات کاتتر گذاری کمتر زمان استفاده طوالنی تر محدودیت حرکت درصد افزایش عفونت Recerculate Vein Stenosis Rubture Of Subclavian آرامش وآسایش بیمار استفاده طوالنی مدت تعبیه سختتر Femoral Vein Subclavian Vein jugularvein 23
24 مراقبت از کاتتر Catheter Care Management 1.شستن دست ها 2. روش استریل 3. ضد عفونی 4.زمان استفاده 5. توجه به عالئم 24
25 مراقبت از کاتتر Catheter Care Management 6. استفاده نا بجا حرکت دادن پانسمان عدم استفاده از وسایل تیز و برنده )... کنترل کاتتر. )تورم التهاب و.10 25
26 مراقبت از کاتتر Catheter Care Management 11.هپارینه نمودن 12. پرسنل مجرب 13. آموزش به بیمار 14.توجه به Dyspenea آمفیزم هماتوم عالئم مانند: 26
27 Nursing Care Plan And Catheter 27 1.Good hand Hygiene 2.Steril gloves 3.Wash The Skin 4.Steriel Method 5.Control Of Catheter 6.Change Dressing 7.Heparinaization
28 عوارض کاتتر Complications Of Central Venous Catherization عوارض ناشی از نصب.1 2.ترومبوز Thrombosis Infection. 3 عفونت 28
29 عوارض ناشی از نصب Arterial Puncture سوراخ شدن شریان Pneumothorax پنوموتوراکس همو توراکس Hemothorax Arrhythmias آریتمی آمبولی هوا Airembolism تامپوناد قلبی Tamponad Re Troperitoneal Hemorhage 29
30 Thrombosis Infection Central Venous Stenosis Arterio Venous Fistulla ترومبوز عفونت تنگی عروق فیستول شریانی وریدی 30
31 آسیب به بافت های مجاور Brachial Plexus Trushe Rubture Recurrent Laryngeal Nerve شبکه بازویی تراشه عصب الرنژیال 31
32 بیشتر در کاتتر گذاری ساب کالوین که بین % ژگولر در %10 موارد ذکر می شود و در مهمترین عامل از دست دادن کاتتر و مرگ ومیر می باشد. Exit Site محل خروج کاتتر Tunnel Infection تونل سیستمیک Catheter Related Blood Stream Infection 32
33 Duration of Catheter Use Time from 1 st Dialysis to Catheter Removal days days 33 حمید احمدیان کارشناس همو دیالیز
34 Understanding Your HEMODIALYSIS ACCESS OPTIONS 34 حمید احمدیان کارشناس همو دیالیز
35 Understanding Your HEMODIALYSIS ACCESS OPTIONS 35 حمید احمدیان کارشناس همو دیالیز
36 Right Atrial Tip Placement Improved Flow Rates Consistent (Reproducible) Flow Rates Zero Recirculation Rate Improved Clearance 36 حمید احمدیان کارشناس همو دیالیز
37 Ante grade Tunneled CHD Catheters Left Internal Jugular Vein Placement Venotomy Location Tip Location Results: 1. Good tip placement, but poor cuff and exit site placement or 2. Good cuff and exit site placement, but poor tip placement 37 حمید احمدیان کارشناس همو دیالیز
38 Step 1: Place Catheter Tips First Left Internal Jugular Vein Placement Benefit #1: Minimizes risk of Catheter tip malpositioning Benefit #2: Minimizes risk of catheter recirculation Benefit #3: Minimize risk of catheter clotting Venotomy Location Tip Location 38 حمید احمدیان کارشناس همو دیالیز
39 39
40 Why cannulations training? Fistulae are technically more challenging than grafts High staff turnover rate = more inexperienced staff Seeing more AV Fistulae Are you using best demonstrated practices? 40 حمید احمدیان کارشناس همو دیالیز
41 Any question?
42 42 با تشکر از
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