What is the next step for a patient who has undergone emergency dialysis?

Next Step After Emergency Dialysis

For a patient who has undergone emergency dialysis, the next step should be the creation of an arteriovenous fistula (AVF) as the definitive vascular access. 1

Rationale for Vascular Access Selection

The KDOQI Clinical Practice Guidelines for Vascular Access (2019) provide clear direction on vascular access planning following emergency dialysis:

1. Initial assessment: When a patient has undergone emergency dialysis with a central venous catheter (CVC), a permanent vascular access plan should be established within 30 days of dialysis start 1

2. Preferred access type: An arteriovenous fistula is the preferred vascular access for hemodialysis due to:

   • Lower infection rates
   • Better long-term patency
   • Reduced morbidity and mortality
   • Improved quality of life

3. Timing considerations: For patients with eGFR 15-20 mL/min/1.73 m² with progressive decline in kidney function, referral for vascular access assessment and creation should occur promptly 1

Implementation Process

After emergency dialysis with a CVC, follow this algorithm:

1. Immediate step: Maintain proper CVC care using aseptic technique while planning for permanent access 1

   • Use chlorhexidine for exit site disinfection
   • Practice proper "scrub the hub" technique when accessing the catheter
   • Follow proper connection/disconnection protocols

2. Within 30 days: Establish an ESKD Life-Plan with a definitive vascular access plan 1

   • Refer to vascular surgery for AVF creation
   • Consider patient's overall medical condition and life expectancy

3. Pre-surgical evaluation:

   • Vessel mapping to identify optimal sites
   • Preserve vessels for future access creation
   • Follow "distal first to proximal next" approach

4. Post-creation care:

   • Monitor for maturation
   • Implement hand-arm exercises to enhance maturation 1
   • Plan for transition from CVC to AVF once mature

Special Considerations

• Maturation period: AVFs typically require 4-6 weeks to mature before cannulation
• Bridging strategy: Continue using the CVC until the AVF is mature and ready for cannulation
• Succession planning: Always consider future access options as part of the ESKD Life-Plan 1

Common Pitfalls to Avoid

1. Prolonged CVC dependence: Extended CVC use increases infection risk and central vein stenosis
2. Premature AVF cannulation: Attempting to use an immature fistula can lead to infiltration and access failure 1
3. Inadequate vessel preservation: Avoid using peripheral veins for blood draws or IV placement in the arm planned for AVF creation
4. Delayed referral: Waiting too long for surgical referral can lead to prolonged CVC dependence

Answer to Multiple Choice Question

Based on the KDOQI guidelines and evidence presented, the correct answer is:

A. Arteriovenous fistula - This is the preferred permanent vascular access for patients requiring ongoing hemodialysis due to lower complication rates and better long-term outcomes 1, 2.