What are the initial steps for managing a vascular access problem?

From the Guidelines

The initial steps for managing a vascular access problem include prompt recognition and assessment of the specific issue, with a focus on preserving vessel integrity and patient safety while maintaining necessary vascular access for ongoing therapy. The management approach should be guided by the principles outlined in the KDOQI clinical practice guideline for vascular access: 2019 update 1.

Key Considerations

• Identify the type of problem (infiltration, extravasation, occlusion, infection, or displacement) through careful examination of the access site and surrounding tissue.
• For occlusions, attempt to restore patency by gently flushing with normal saline using a 10mL syringe; if unsuccessful, thrombolytic agents like alteplase (2mg/2mL) may be required, as suggested by the need for effective management of AV access flow dysfunction 1.
• For infiltration or extravasation, immediately stop any infusion, elevate the extremity, and apply warm or cold compresses depending on the infusate (cold for vesicants, warm for non-vesicants).
• For suspected infection, remove the catheter if appropriate, obtain cultures from the site and blood, and initiate empiric antibiotics such as vancomycin 15-20mg/kg IV for suspected gram-positive organisms while awaiting culture results.
• Document all interventions, including the time of detection, assessment findings, and actions taken, emphasizing the importance of a patient-focused approach and the development of an ESKD Life-Plan 1.

Evidence-Based Recommendations

The KDOQI guideline emphasizes the need for high-quality standards in vascular access care, with a focus on patient-centered outcomes and the prevention of complications 1. The guideline also highlights the importance of multidisciplinary care and the need for ongoing research to address gaps in knowledge and evidence in vascular access care 1.

Prioritizing Patient Safety and Vessel Integrity

Proper management of vascular access problems is crucial to prevent tissue damage, systemic infection, or loss of venous access, potentially delaying critical treatments. By prioritizing patient safety and vessel integrity, healthcare providers can ensure that patients receive the necessary care to maintain their vascular access and achieve their dialysis goals, as emphasized by the guideline's focus on reliable, complication-free access to deliver prescribed dialysis 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Cathflo® Activase® (Alteplase) is for instillation into the dysfunctional catheter at a concentration of 1 mg/mL If catheter function is not restored at 120 minutes after 1 dose of Cathflo Activase, a second dose may be instilled Instillation of Solution into the Catheter Inspect the product prior to administration for foreign matter and discoloration. Withdraw 2 mL (2 mg) of solution from the reconstituted vial. Instill the appropriate dose of Cathflo Activase (see DOSAGE AND ADMINISTRATION) into the occluded catheter. After 30 minutes of dwell time, assess catheter function by attempting to aspirate blood If the catheter is functional, go to Step 7. If the catheter is not functional, go to Step 5. After 120 minutes of dwell time, assess catheter function by attempting to aspirate blood and catheter contents.

The initial steps for managing a vascular access problem include:

• Inspecting the catheter for foreign matter and discoloration
• Instilling the appropriate dose of Alteplase into the occluded catheter
• Assessing catheter function after 30 minutes of dwell time by attempting to aspirate blood
• Re-assessing catheter function after 120 minutes of dwell time if the catheter is not functional
• Administering a second dose of Alteplase if catheter function is not restored after the first dose 2

From the Research

Initial Steps for Managing Vascular Access Problems

When managing vascular access problems, it is essential to consider the following steps:

• Identify the type of vascular access complication, such as thrombosis, infection, or hemorrhage 3, 4
• Assess the patient's overall condition and medical history to determine the best course of action 5
• Consider the use of vascular closure devices, radial artery access, fluoroscopic guidance, and ultrasound guidance to minimize complications 3
• Develop a plan for managing the complication, which may include surgical or percutaneous interventions, anticoagulation therapy, or other treatments 4, 6

Key Considerations

Some key considerations when managing vascular access problems include:

• The risk of symptomatic pulmonary embolism after percutaneous thrombolysis 4
• The importance of strict adherence to a regimented protocol of surgical technique and catheter care to minimize complications 5
• The benefits of using arteriovenous fistulae (AVF) for hemodialysis access, which have the lowest infection and thrombosis rates and are associated with the best morbidity and mortality outcomes 6

Additional Factors

Additional factors to consider when managing vascular access problems include:

• The role of national and international guidelines in providing feasible solutions to clinical problems 7
• The importance of a multidisciplinary approach to vascular access care, involving nephrologists, dialysis staff, interventional radiology, and vascular surgeons 7