LESLEY DINWIDDIE

Connie Andersen, MBA, RN, of Northwest Kidney Centers, Seattle, Washington, gave an overview of training for home dialysis, listing the necessary components of a successful home hemodialysis training program. She stressed that a home program must start with a commitment from the management organization, and it must also have integrated systems for training, support, and ongoing home follow-up care. These systems must be well organized, user friendly, and easily accessible to the home patient in order to achieve the primary goal of maximum patient well-being and independence. Components of a successful home training program begin with the identification of suitable patients, followed by a stepwise process from evaluating the home through training and patient support. Ms. Andersen closed with projections for the future of home training programs that included regionalized programs and the implementation of new technologies.

The subject of nocturnal hemodialysis always raises the issue of access safety. Michaelene Ouwendyk, RN, Humber River Regional Hospital, Toronto, Ontario, reviewed the Toronto experience utilizing both the Uldall catheter and the native AV fistula, reporting a total of 650 patient-months’ experience with the Uldall catheter. Safety measures utilized for this catheter include the “interlink” system to prevent air embolism, a “nocturnal locking box” that fits around the connection to prevent accidental disconnection of the blood lines from the catheter, and the “nocturnal armband” which prevents tugging on the catheter during sleep. Six patient-months of experience utilizing “buttonhole” cannulation of the AV fistula were shared, again demonstrating innovative safety equipment, including “Supercath” Teflon™ catheters, the “Immobile AC®,” and a nocturnal wrist band. Trials using a single-needle cannula system are in progress.

Nursing assessment of vascular access for hemodialysis was the topic presented by Lesley Dinwiddie, MSN, RN, University of North Carolina– Chapel Hill. Initial assessment includes a thorough history in addition to a physical examination that includes inspection, auscultation, and palpation of the access. The physical exam is part of every dialysis session. Ongoing routine monitoring can be by venous pressure monitoring using dynamic or static pressures, flow measurements, adequacy computations, cannulation variables, and subjective complaints. Consistency of monitoring and analysis of measurement trends are the key to early detection of access problems and preservation of the access through early intervention.

An in-depth explanation of the buttonhole technique of cannulation was given by Jerry Wells, RN, Dialysis Clinic, Inc., Columbia, Missouri. He reviewed the three current techniques for needle insertion with illustrations of “rope-ladder puncture” (equal distribution of punctures along the whole length of the fistula vein), area puncture (confining many sticks to the same small area), and the buttonhole, which utilizes the same needle hole track for each cannulation, and discussed the complications of each. Because area puncture leads to aneurysmatic dilatation and stenosis of the fistula, it should not be used. The establishment of a new buttonhole over a 4-week period was detailed, as well as the art of cannulating an established buttonhole.

The final presentation in this “how-to” session was the “Use of Intradialytic Urokinase for Clotted IV Access,” presented by Jerri Everage, RN, Dialysis Clinic, Inc., Columbia, Missouri. With the increasing use of catheters, clotting in the catheter and subsequent decreased blood flow presents a major problem. A review of previously used protocols for urokinase demonstrated the need for an innovative method for intradialytic urokinase in varying dosages and regimens. A protocol combining intradialytic urokinase and warfarin to maintain patency was described. Access outcomes were presented along with the negligible complications.

Ms. Everage concluded that intradialytic urokinase administration was safe, effective, efficient, and cost effective.