Hemodialysis patient survival is dependent on the availability of a reliable vascular access. In clinical practice, procedures for vascular access cannulation vary from clinic to clinic. We investigated the impact of cannulation technique on arteriovenous fistula and graft survival. Based on an April 2009 cross-sectional survey of vascular access cannulation practices in 171 dialysis units, a cohort of patients with corresponding vascular access survival information was selected for follow-up ending March 2012. Of the 10,807 patients enrolled in the original survey, access survival data were available for 7058 patients from nine countries. Of these, 90.6% had an arteriovenous fistula and 9.4% arteriovenous graft. Access needling was by area technique for 65.8%, rope-ladder for 28.2%, and buttonhole for 6%. The most common direction of puncture was antegrade with bevel up (43.1%). A Cox regression model was applied, adjusted for within-country effects, and defining as events the need for creation of a new vascular access. Area cannulation was associated with a significantly higher risk of access failure than rope-ladder or buttonhole. Retrograde direction of the arterial needle with bevel down was also associated with an increased failure risk. Patient application of pressure during cannulation appeared more favorable for vascular access longevity than not applying pressure or using a tourniquet. The higher risk of failure associated with venous pressures under 100 or over 150 mm Hg should open a discussion on limits currently considered acceptable.

The risk of an acute VA complication could be reduced with appropriate training of nurses, physicians and patients. This could potentially prolong the VA life.

Due to the characteristics of plastic cannulae, they seem to be well suited for restless patients, patients with unpredictable behaviour, children, and patients who are allergic to metal.However, the evidence base provided by studies on the use of cannulae is currently weak. More controlled randomised studies are needed.

This survey covered a broad number of countries and centers and provides information on current practice of vascular access cannulation, their effect on dialysis dose, and serves as feedback to the dialysis centers for their quality management process.

BackgroundPatient survival and quality of life depend on each haemodialysis session being performed without fault. Monthly assessments of dialysis dose adequacy often fall short of this. This study reports the results of a feasibility study for the achievement of improved safety and quality in a haemodialysis session with the implementation of a 15-point checklist.MethodsFifteen quality indicators were compiled and tested in a Portuguese dialysis clinic from 1 February 2012 to 30 June 2013. The checklist was completed by the nursing staff and comprised three parts: Pre-session Safety Checks; Session Initiation Checks and Post-session Quality Checks. The maximum score that could be reached per session was 15.ResultsOne hundred and twenty-eight patients were distributed over 2–3 shifts. Of the 16 nurses employed, 4 were full time. The final average score was between 14 and 15. No nurse-specific and no shift-specific significant differences were detected. Four issues were identified that had a major effect on the results as a whole: delays in connection time; incompletely delivered treatment time; non-achievement of final body weight and failure to reach a Kt/V of at least 1.4. Improvements were most consistent in the Monday–Wednesday–Friday morning shifts compared with other shifts, and were temporarily compromised by the opening of a new shift.ConclusionsThe implementation of checklists for haemodialysis is feasible in routine clinical practice, even in clinics where only part of the staff is employed full time. The application of such checklists enhances the overall quality and safety of the delivered treatment.

A good functioning vascular access (VA) is a prerequisite to obtain a successful dialysis treatment. This chapter reviews VA management in advanced chronic kidney disease (CKD) patients drawn from the experience of a large network dialysis care provider with the following sections: overview on VA management in advanced CKD that follows patient pathway and patient profile, current practice patterns in line with best clinical practices; VA creation addressing crucial themes: when and what type of VA to construct, how to assess patient pre-emptively, how to proceed for the construction and monitoring to prevent early failures and complications; VA management with particular focus on clinical monitoring, surveillance and interventional procedures required to preserve patency and functionality of VA; the often-forgotten patient perspective is VA usage. What information to share, how to proceed for preventing pain, and fears related with VA needling? What should patients know about their VA and how to manage in daily life? Competences, skills and responsibilities of nursing staff when using and managing VA; and future of VA in terms of innovative concept for creating and maintaining VA conduits in dialysis patients.

Peritoneal teledialysis (telePD) is a modembased communication link between the patients' cyclers and a computer in the dialysis unit that allows the transmission and storage of a series of automated peritoneal dialysis (APD) treatment data. In order to evaluate the usefulness of telePD in quantifying the problems that may occur during pediatric APD, we retrospectively studied four patients with a median age of 14.1±1.8 years during their initial months of telePD. The selection criteria were potential non-compliance in two cases (patients 1 and 2) and catheter malposition or fibrin occlusion in two (patients 3 and 4). The patients were treated using a Fresenius PD Night Cycler with teledialysis software. Thirty consecutive treatments per patient in the 1st and 4th months were examined, and a series of treatment parameters was calculated. The percentage of treatments with alarms and the number of alarms per treatment were high in both the 1st and the 4th month, particularly in patients 3 and 4. The main causes of the alarms were tube kinking, catheter malfunction, fibrin occlusion, and failure of electrical power. The number of shortened treatments significantly decreased in the 4th month of tele-PD. One non-compliant family was identified during the 1st month of PD, but psychosocial support helped to decrease the number of shortened treatments due to noncompliance in the 4th month. During the 4th month of telePD, the dwell time/total treatment time ratio (which represents the time of contact between the peritoneum and dialysis fluid) increased as a result of technical interventions aimed at reducing the infusion plus drain time.In conclusion, telePD proved to be useful in detecting and solving the clinical and technical problems of APD.

Vascular access is the key part of haemodialysis (HD) treatment, as this is not possible without a functioning access. The use of the arteriovenous fistula (AVF) has fewer complications, lower mortality and fewer hospital admissions compared to central venous catheter (CVC). However, although guidelines recommend AVF as the access of choice, access-related cannulation complications may lead to greater morbidity. Most guidelines recommend using Doppler ultrasound (DU) to surveil the AVF for HD, but its use must not only be limited to surveillance as it can also be used for needling. Therefore, among those techniques at our disposal today, one of the best tools for AVF needling is Doppler ultrasound (DU). Despite the lack of evidence regarding ultrasound-guided needling of AVF, it is becoming part of our usual practice arsenal in many HD centres. Its use has allowed needling results to improve and the number of complications to be reduced versus traditional ‘blind’ needling. It should be remembered that even though it is very useful for the daily work of dialysis nurses, as in the case of other techniques, it requires adequate, specialised and long-term training to acquire competence in using it. For example, it is important to learn some concepts and terminology that should be known and, at the same time, be highly familiar with different techniques available. Two types of needling techniques are described using US assistance: US-guided needling, where DU is used to make a map of the vessels which can be utilised and to mark the best site to insert the needles once the mapping is done; and real-time US-guided needling, the simultaneous manipulation of the probe and the insertion of the puncture needle through the slice plane of the ultrasound device. Regarding the real-time technique, there are two approaches: out of plane (the probe takes a transversal image of the needle) and in plane (vessel axis aligned with the probe and the needle in the same plane) To ensure successful needling and to maximise reproducibility, especially with tight deadlines and staff resources, nursing staff need to follow some important recommendations that include safety and the use of the method, both for them and the patient. In this way, ultrasound-guided needling becomes a tool with enormous potential utility, but practical training is as important as knowing the technique.