3rd Dialysis patient class

Topic: fistula care

Why do dialysis patients need fistulas?It is important to send plenty of the patient’s blood to the machine to be cleaned for a limited time (usually 4 hours).

It’s not easy to do it using our normal blood vessels.

First let us learn about our normal blood vessels, and then learn about fistulas.

We have two kinds of blood vessels

Arteries: Blood vessels send blood from the heart to the body. Their walls are thick and strong because blood is flowing with a strong force in these vessels.They run deeper in the body

Veins: Blood vessels send blood from the body to the heart. Their walls are thin and soft because blood is flowing gradually in these vessels. They run close to the body’s surface.

This artery and this vein will be joined by surgery.This is a fistula.

This is a fistula!!

Blood will be flowing with a strong force from the artery into the vein which is running close to the surface.

It will be possible to send a large volume of blood to a dialysis machine with placing a needle in the vein(fistula).

The fistula can usually be used for several years- even more than 10 years.Sometimes it might cause complications or fail sooner.

Let’s study about fistula care in order to keep your fistula in good condition for a long time.

Daily care of fistula.

Important points

Not to block the fistula flow.

Not to cause bleeding or internal bleeding.

Prevent infection.

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Check the vibrations (it’s called thrill) by touching it with your hand at least 1-2 times a day.

Feel the vibrations

Essential care

Don’t put your head on your fistula arm.

Don’t hung a bag on your fistula arm.

Don’t put anything heavy on your fistula arm.

Don’t lie with your fistula arm under your body.

Don’t put a watch on your fistula arm.

Don’t take blood pressure on your fistula arm.

Don’t take a blood sample from your fistula arm except at a dialysis time.

Don’t wear tight-sleeved clothes.

Don’t hit your fistula. Don’t knock your fistula against anything.

Keep your fistula arm clean.

Don’t scratch fistula arm.

If you get a rash on your fistula, show it to a dermatologist and start treatment soon.

If your fistula is thin, do the following exercise. It is desirable to do this as frequently and for as long as possible.

<Bending and stretching of the elbow><Holding a soft ball>

You can start this the day after the operation.

You can start this one week after the operation.

Before coming for dialysis treatment

Wash and clean your fistula arm from tip of finger to the top of the arm.

Dialysis treatment time

<Signs of BP falling> nausea vomiting rapid heartbeat yawning feeling hot sweating

Prevent BP falling.

Call nurses and request them to check BP when you feel.

Removing too much fluid easily causes low BP, and reduces the blood flow in a fistula. Then, the fistula might weaken or collapse.

normal BP

Low BP

The pressure in the fistula is enough to keep it in good condition.

Very low BP

The pressure in the fistula is also low, and not enough to keep it in good condition. This sometimes causes permanent fistula failure.

Why is falling BP bad for fistula?

Cross section of the fistula.

Removing too much fluid makes the blood thick, and might cause a thrombus in the fistula. (especially when the patient has high hematocrit and hemoglobin.)

Also

The fluid intake for dialysis patients should be less than urine output + 500ml per day. Control your fluid intake.

Have you forgotten?

The recommended weight gain limit between each dialysis treatment is less than 6% of DW (target weight).

Don’t let us prick with the needles in the same place every time.

Pricking in a new place is little bit more painful and difficult for the nurses, but it good for the fistula. Please understand this.

CHANGE THE PLACE!

If we prick in the same place many times,

Why is it bad for the fistula to prick the same place every time?

High blood flow from artery

Fistula wall also becomes thin and very weak!!

High blood flow pushes at the weak place.

A lump is made.

Skin becomes worn and weak.

Then, germs can easily enter from the weak place of the skin and fistula wall into the blood, and might move to other places.

To the heart

To the brain

To the joints

To all places in the body(sepsis)

Blood can carry the germs to every part of the body.

If we continue to prick the lump…

Someday,

Rupture might occur.

Also

Pricking on the same place might cause stenosis.

Also

Press the sites after taking out needles in the proper way.

After dialysis

*If you can’t press the sites properly, this might cause bleeding, internal bleeding or haematoma. These sometimes cause permanent fistula failure. *If you touch the sites with dirty hands, the patient might get infection.

Clean your hands and protect your patient from germs.

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You might need to wear gloves for some patients.

・ Put one hand on one site. Use both hands.

・ Use 2 or 3 fingers of each hand.

・ Lay your fingers flat. 　 Don’t use the tips of your fingers.

※This is the basic way. It will not always be effective for all patients.

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It is important to press covering both holes situated a little way apart.

One hole is on the skin.

One hole is on the fistula wall.

So use 2-3 fingers on the site, lay the fingers flat, then press on both holes.

・ Press a little strongly for 2-3 min.

・ Bleeding will usually stop in this way.

・ Change the gauzes to small clean ones.

・ After that, gradually reduce the pressure for 5-10 min.

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The following methods are not recommended.

Using only one hand.

Using only one finger for one site.

Using finger tips

When using these ways, it is easy to move the sites of the fingers and fail to stop the bleeding.

Watching TV.

If the patient needs to do the pressing himself, as each needle is removed, he should deal with each site separately.

This method is most successful.

Take the gauze pieces off the next day.5

If you don’t remove the gauze, it might get dirty and cause infection. Germs like blood and wet places.

What should you do in these following cases?

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Cool the place for that day. Warm the place from the next day. Check the thrill(vibration) very often.

Internal bleeding or swelling

In this case, blood is bleeding under the skin. Cooling helps to stop bleeding and absorb the leaked blood into subcutaneous tissue.

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Too cold or too hot can cause frostbite or scalding.Check your skin during cooling and warming very often.

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Cannot feel thrill(vibration)

Massage and warm your fistula.

Lie down on bed, and your BP will rise. Low BP often causes fistula weakness.

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3 If the thrill does not return, show to nephrologist or dialysis nurse.

NO THRILL!!

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Complications of fistula

These following cases need to be shown to a nephrologist.

High venous blood pressure

If upside of fistula is closed or very narrow, a lot of blood from the artery cannot return to the heart.

Then, that blood goes down to the hand, and stays there, causing swelling.

Sore thumb/sore hand syndrome

If ‘High venous blood pressure’ becomes worse, it causes finger or hand pain.

It sometimes causes ulcers on the fingers.

Steal syndrome

If most of the blood that should be sent to the hand or fingers goes to a fistula, then the hand or fingers cannot get enough blood.

Coldness, numbness or pain may occur.

In a serious case, ulcers may occur.

aneurism

Not all aneurism are dangerous. Show to nephrologist in the following cases.

It is glossy. It is growing rapidly.

There is a risk of aneurism rupture in these cases.