Clotted Grafts

nursefiggy · Nov 8, 2003

Sounds like someone just couldn't stick. If there is a thrill and bruit then it is not clotted. I bet the same nurse was charge on all three occasions.

jnette, ASN, EMT-I · Nov 8, 2003

Had two go down today. One a fistula, the other a graft. In both cases, no thrill or bruit. The one I stuck myself, and knew immediately when I got no flashback in the arterial stick, what little blood I DID get was nearly black... always a good sign of having clotted off.

The other was a new fistula... this poor woman is on her third attempt at both grafts and fistulas. Anyway, it had been working fine the past two weeks, then today, nothing ! Gone.

Wierd... we send them to have them opened up, and they tell us they're fine... doppler or no, I say they need to be cannulated there before returning to us ! If you can cannulate and dialyze, great ! 'Cuz so often when they come back to us, we STILL cannot cannulate them or get them to run... we have GREAT "stickers", too ! These folks have been doing this for up to 12 years.. same experienced staff.. not "newbies". But this happens more with the caths.

drscepura, BSN, DNP, RN · Mar 3, 2004

Sounds like the outpatient center sent you problem patients maybe because they were being a pain in the rear that day and didn't want to deal with their access issue themself. When patients have low blood pressures, and many elderly outpatient dialysis patients walk around with BP's of 70's and 80's, a nurse may not be able to hear or even feel a bruit or thrill. In a younger patient with newer access you may have better luck. Really it depends on the patient. I would still attempt to cannulate if I didn't feel or hear anything. Like one nurse suggested if the blood that returns is slow moving and dark red/black then you know that the access is clotted and this is an emergent issue that needs to be addressed immediately. Before you send them however, you want to check what last K was and if you can do a peripheral on other arm/vein then by all means get one (a stat K) and send, if you are in a chronic unit in hospital setting.

nurse dolly · Mar 4, 2004

My frustration level is at a all time high!!!!In the last week our outpatient dialysis center sent us 3 "downed" grafts....clotted etc.. Upon the patient comming in to the hospital, a short stay bed being arranged, a hep lock put in, and blood work done, a color flow doppler was also done...All three were wide open. I am curious, how do dialysis nurses in you centers know if a fistula/graft is down? All three of the grafts had a palpable thrill and an audible bruit. Is this negligence or is it difficult to tell when a graft/fistula is clotted? Do any other outpatient centers have this problem? Can anyone share with me the catheter to graft/fistula ratios? What are your hematoma rates? Any information would be greatly apprieciated.

sounds very strange if you cant feel a thrill or hear bruit then it is clotted. Maybe they had other problems with the access like bad clearances or unable to monitor arterial pressure and venous pressures over 100 at blood pump speed of 200.

Hellllllo Nurse, BSN, RN · Mar 4, 2004

Over half of the dialysis pts at my unit have caths. I am very frustrated with surgeons who can't put in a good cath. We send pts to have non-functional caths replaced because the tips are suctioned to the vessel wall when we try to use either side as arterial. The hospitals flush the lines and send the pts back to us saying the lines are fine fine. What they don't understand is that we must be able to pull from at least one line, not just flush.

jnette, ASN, EMT-I · Mar 4, 2004

Over half of the dialysis pts at my unit have caths. I am very frustrated with surgeons who can't put in a good cath. We send pts to have non-functional caths replaced because the tips are suctioned to the vessel wall when we try to use either side as arterial. The hospitals flush the lines and send the pts back to us saying the lines are fine fine. What they don't understand is that we must be able to pull from at least one line, not just flush.

Oh, how I DO agree !!! :angryfire ..and IF they even go so far as to attempt a "trial run" before sending the patient back to us, they have these patients in a supine position, in BED. We do not. So while they might run lying down, they sure don't run worth a hoot sitting up !

One of our new patients had a cath that needed a "one on one" for nearly two weeks... could barely get a 200 blood flow rate. It was strictly positional. The poor man was so frustrated, and rightly so... not to speak of us, who had to run over there literally every two minutes to catch the alarm and ask him to cough, deep breathe, raise his arm, try trendelenburg... you name it. Finally his surgeon agreed to have him come down... two hours drive, mind you. They told us they would dialyze him there that day... do you know the surgeon never even LOOKED at the cath !!! Asked him what the problem was, and that this was for his nephrologist to look into ! :eek:

He was back the next day... same thing. Well, our nephrologist apparently got on the horn with the surgeon and sent him back. THIS time the surgeon corrected it... come to find out, he had placed the wrong catheter in... and never realized it until he actually looked at it ! SHEEEEEEEEEESH !!! But take OUR word for it...??? Nooooooooooooo.

So they put another cath in (more surgery for this poor little man)... but halleluliah, this one actually WORKS !!! Runs like a charm. Little guy is smiling from ear to ear.. and so are WE !

drscepura, BSN, DNP, RN · Mar 4, 2004

Be careful with those stop and go stop and go catheters. I had a young pediatric patient who was receiving heparin and the machine kept alarming low arterial pressure, the pump was only at 200. After trying to reverse the lines, and then finally re-reverse the lines back I noticed on the venous port there was a huge sludge like clot formed inside the lumen of the catheter. Luckily, nothing happened to the child, the attending physician happened to be standing right there and witnessed the entire event. We were sort of in quandry, couldn't pull from the venous port and there was noticeable long spaghetti like clot there. I suctioned out what I could, and had no other choice but to flush it with NS. Flushing that port was the scariest thing that I have ever had to do in my career. Luckily, child was fine, we TPA'd the ports but child eventually had to have a new line. The start and stop of the pump with low arterial pressure is not something to take lightly. You just don't walk over to machine and hit reset and think all is well. Really investigate what is going on with the catheter. Also, for those outpatient nurses who are stating that inpatient dialysis nurses don't understand the frustration with poor functioning catheters, along with the multitude of position changes (flat, sitting, side lying, arm down, legs above head, etc. :-) ) is just hogwash. We send patients to outpatient units if at least one of the ports has a glide and pull, and a somewhat decent QB. Every patient is unique, and you are not going to get the flows that you want without having to nurse your catheter situation. Unfortunately, dialysis patients move while they are on the machine, and the alarms are set off. Think about the vasculature of a dialysis patient, a good portion of them are diabetic, aged and the poor functioning catheter may be the only chance they have at survival. It's not like you can just keep putting in new line after new line without having more problems. Ever hear of stenosis? I offer this: get the best steady QB you can, if continuously below 200-180 than you need intervention depending on what labs are showing. Perhaps they need their time lengthened if the catheter runs at a slower flow, but doesn't start and stop continuously. What Renal Fellows and Nephrologists have a hard time understanding, along with Surgeons, is that is you have no PULL from a catheter on both ports you can't sustain the PULL of the machine. NO PULL MEANS NO PULL, and NO PULL MEANS NO DIALYSIS. That is all you have to say to them to get them to get it, it's not rocket science. Sometimes you have to pull them over and show them, make them put gloves on and attempt to aspirate and understand that there is no glide. They think that if they can push into it everything is hunky dorey, well it's not. Hope this helps!