Change Concept 9

Monitoring and maintenance to ensure adequate access function

  • Nephrologists and surgeons conduct post-operative physical evaluation of AVFs in 4 weeks to detect early signs of failure and refer for intervention as indicated.
  • Facilities adopt standard procedures for monitoring, surveillance, and timely referral for the failing AVF.
  • Nephrologists, interventional radiologists, and surgeons adopt standard criteria, and a plan for each patient, to determine the appropriate extent of intervention on an existing access before considering placing a new access.

The health care team should establish a process for monitoring and maintenance of AV fistulae to ensure adequate access function. It is extremely important to catch problems with fistulae early. Problems must be caught within 24 hours or the fistula will fail and be irreparable. There is a 20 to 30 percent failure rate for early fistulae.

Changes for Improvement:

Conduct a Post-Operative Physical Evaluation of AVFs at 4 Weeks
Nephrologists and surgeons should conduct post-operative physical evaluations of AV fistulae at four weeks to detect early signs of failure and refer for diagnostic study and remedial intervention as indicated.

Adopt Standard Procedures for Monitoring, Surveillance, and Timely Referral for the Failing AVF
The K/DOQI has established recommendations and guidelines for monitoring and surveillance:

Monitoring, which K/DOQI defines as physical examination techniques to detect access dysfunction, has been shown in many studies to be able to identify the majority of patients with AV fistula dysfunction.

Surveillance involves the use of a variety of tests to detect access dysfunction. Intra-access blood flow measurement over time is the best surveillance method available for assessing AV fistula function and detecting dysfunction.

Two other methods offer significant value for AV fistula surveillance:

Pre-pump arterial pressure, which is measured on almost all dialysis machines, indicates the ease or difficulty with which the blood pump is able to draw blood from the access (inflow). A significant restriction of inflow will cause an excessively negative pre-pump arterial pressure. Since most causes of AV fistula dysfunction are inflow problems, an excessively negative pre-pump arterial pressure is often the earliest indication of such a problem.

Access recirculation measurement. An AV fistula may remain patent but not provide enough blood flow to meet the prescribed blood pump flow rate, resulting in underdialysis. If there is any question about adequacy of blood flow for dialysis, or if there is difficulty dialyzing the patient at the prescribed pump rate, a recirculation study will determine if the AV fistula blood flow is not sufficient to meet the prescribed blood pump flow rate.

Note: While physicians commonly use venous pressure measurement to detect access dysfunction, it is of very limited value in AV fistula surveillance. This is because most of the flow-limiting problems in AV fistulae are on the arterial of the venous needle (and often the arterial needle as well) and therefore are not detectable by pressure measurements made at the venous (or arterial) needle, which can only detect an outflow obstruction downstream of the measuring needle(s). In addition, the fistula has tributaries that can dissipate pressure in the presence of an outflow obstruction. Finally, access pressure measurements are not likely to identify centrally located venous obstructions.

Adopt Standard Criteria and a Plan for Each Patient
Nephrologists, interventional radiologists, and surgeons should adopt standard criteria, and a plan for each patient, to determine the appropriate extent of intervention on an existing access before evaluating and mapping for an AV fistula.

Related Tools

AVF Physical Examination Made Easy- Videos

These video segments are currently available for viewing on PC’s only.

Developed 11/11:  Tushar Vachharanjani, MD, FACP, FASN, Dialysis Access Group of Wake Forest University School of Medicine, Winston-Salem, North Carolina.

These animated videos will instruct the user to perform complete and proper physical exams of an arteriovenous fistula (AVF).

Physical Examination of AVF

Continuous Circuit

Arm Elevation Test

Augmentation Test

Outflow Stenosis

Accessory Vein

AVG Assessment and Intervention Algorithm

This tool will assist facilities to improve consistency of AVG assessment and intervention, as well as commuication efforts with surgeons,  nephrologists and interventionalists.  Developed February 2012

Detection of Access Dysfunction in Permanent Vascular Access [AV Fistula (AVF) & AV Graft (AVG)] for Dialysis Facility Staff 

Developed 08/10
This tool will help dialysis facility staff to identify persistent abnormalities in monitoring and surveillance of AVFs and AVGs.

Procedure for Assessing and Monitoring Newly Placed AV Fistulas for Maturation 

Developed 04/10
This tool provides timely interventions for AV fistulas which are failing to mature, includes detailed instructions for physical examinations

Monitoring the Newly Placed AV Fistula for Maturation Algorithm

Developed 04/10
This flowchart provides timely interventions for AV fistulas which are failing to mature, includes physical examination description.

Referral Form for Existing Hemodialysis Access

From: National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

This form can be used by nephrologists to refer a patient with existing hemodialysis access to a surgeon or interventionist. The form indicates the reason for referral and procedure requested, as well as current hemodialysis treatment and vascular access information.

AV Fistula – Failure to Mature

This document contains a “Fistula Failure-to-Mature” Scan that can be utilized as part of a Quality Assessment and Performance Improvement (QAPI) program in any dialysis facility.

AV Fistula – Quick Reference Guide

An easy-to-use reference document that describes the maturation process, and guidelines for assessment and monitoring of AV fistulas.

Request for Immediate Surgical Intervention

This one-page fax back form contains critical information that would be required by a dialysis facility to ensure safe intervention of peripheral vascular access.

Permanent Vascular Access Algorithm Surveillance/Intervention

This one-page algorithm can be utilized for patients with a graft or AV fistula.  It can serve as a guide that aids caregivers in identifying clinical and hemodynamic indicators that an access is in need of being evaluated for revision or replacement.

Listen for the Bruit

An excellent tool for patient care staff to learn to differentiate normal versus abnormal fistula and graft sounds.

From: Tushar Vachharajani, MD, FACP, FASN, Associate Professor Internal Medicine/Nephrology, Director, Dialysis Access Group of WFU, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA

Infection Tracking Log

This is a comprehensive facility infection tracking log that can be used for AVF’s, grafts, catheters (tunneled and non-tunneled), and peritoneal accesses.  The Tracking Log includes columns for documenting associated symptoms, culture results, treatment plan, and outcomes.