Temporary acces methode and

permanent acces
Metalia Puspitasari
Pendahuluan
 TYPES

• Temporary access

• Permanent access
 TEMPORARY ACCESS

• The necessity for temporary access may vary

from several hours to few months.
• It is by the percutaneous insertion of a
catheter into a large vein.
• Catheter access is temporary if the renal
failure resolves or if a another form of
functional permanent access can be created.
 TYPES OF CATHETERS

• Temporary catheters [non-

tunnelled, un-cuffed
double-lumen catheter]

• Permanent catheters
[Tunnelled, cuffed
catheters]
 TEMPORARY CATHETERS
• Temporary catheters are composed of
polyurethane which is stiff at room
temperature to facilitate insertion but
softens at body temperature to minimize
the vessel trauma.
• Temporary catheterization should be done
in operating rooms or in dialysis procedure
room under aseptic technique.
• X-ray should be taken after
catheterization before
starting dialysis to verify
the catheter is in correct
placement.
• Catheter length varies
greatly to accommodate
proper positioning of the
tip.
 INSERTION LOCATION
• The optimal insertion site is
right internal jugular vein.

• 15cms temporary catheter are

inserted.

• Catheter lumen size varies

from 9 to 16 french.
• Ultrasound allows the
operator to examine the
vein for anatomical
abnormalities and to
directly visualize the
patient and the rate of
carotid artery punctures is
greatly reduced.
• Left intra-jugular vein is
avoided because it provide
less blood flow and it is
removed due to
malfunction.
 Probe Selection
• Linear
– 7.5Mhz, Vascular, Soft Tissue, Ocular
• Phased Array
– 5-1Mhz, Echo, Abd, OB, ?Vascular Access
• Pros and Cons
 Technique
• Transverse
• Longitudinal
• Common
– Position equipment
– Prep sterile supplies
and patient
– Get Sterile
– Sterile probe cover
Technique
 Technique
• Transverse
– ID and Center Anatomy
– Pythagorean Theorem
– ID depth to center of
vessel
– Back off the transducer
equal distance
– Enter at 45 degree angle
• Femoral catheters are used
for hospitalized, bedridden
patients.

• The size of the femoral

catheters should be atleast 20
cm so that the tip is in the
inferior vena cava to permit
better flow and to minimize
recirculation.
PERMANENT CATHETERS
• It is used for long term access for patients in whom AV
access cannot be readily created such patients include-
 small children
 diabetic patients with severe vascular disease
 morbidly obese patient and
 patients who have undergone multiple AV access
insertions and in whom additional sites for AV access
are not available.
• Dacron cuffs are bonded to the catheter to
reduce the incidence of line-related infection
and catheter migration.
• Silicone and polyurethane are less
thrombogenic than materials such as Teflon
and polyvinyl used in the past.
• The walls of the lumens of silicone catheters
must be thicker than polyurethane catheters.
PERMANENT ACCESS
 ARTERIOVENOUS FISTULA

• An AVF is formed by
subcutaneous anastomosis of
artery and vein.
• Its maturation period is 4 to 6
weeks.
• During this interval the flow in
the fistula increases and the
vein wall thickens.
• Fistula is created in the non-
dominant hand.
 INDICATIONS
INDICATION:
• Patients with GFR < 30 ml/min [ CKD stage 3 ]
 LOCATIONS

There are nine potential sites for

AV fistula can be found in the
upper extremity.

• Radio-cephalic fistula [Brescia-

cimino]

• Brachio-cephalic fistula [Gracz

fistula]
• Snuff-box fistula

• Radio-median
antecubital fistula
• Ulnar basilic fistula

• Wrist ulnar basilic fistula

• Transpose brachio-basilic
fistula

• Brachio bi-directional
cephalic fistula

When all sites in the non-

dominant arm have been
exhausted, the dominant
arm can be used.
 CONSTRUCTION
The anastomosis can be made either,
• Side of artery to side of vein
• End of artery to end of vein
• Side of vein to end of artery
• End of vein to side of artery
 FISTULA CARE

• AVF is created in non-dominant

hand.
• Excercise for 5 to 10 mins for every
1 hour.
• Tight dressings should be avoided.
• Do not check BP in fistula hand.
• Avoid hypotension
• Do not take blood samples.
• Avoid giving injections in fistula
hand
• Avoid lifting heavy objects and avoid doing
work.
• Do not sleep in fistula hand by keeping the
hand beneath the head.
• Sutures are removed after 15 days of AVF
creation.
• Use aseptic technique for cannulations.
• Perform cannulation in ladder-rope technique.
 ARTERIO-VENOUS GRAFT

• When an adequate AV fistula cannot created

an AV connection using graft tube is the next
preferred type of vascular access.
• An AV graft is similar, except the distance
between artery and vein is bridged by a tube
made of prosthetic material.
• An AV graft can be used earlier fistula, but a
delay fo 1-3 weeks is recommended to allow
the healing to occur around the graft
minimizing extra-vasated blood after the
needles are removed.
• AV graft are much less desirable than AV
fistulas.
• Most AV grafts are composed of expanded
polytetrafluoroethylene (PTFe).
 ADVANTAGES

• Large surface area for needle placement

• Easy cannulation
• Short maturation time
• Easy surgical handling characteristics.
 DISADVANTAGES
• Infections
• Thrombosis
• Severe bleeding
• Central vein stenosis
TERIMA KASIH