fistula info for the non dialysis RN

[canoehead, BSN, RN]

I had a near code in the ER who had no IV access but had a fistula. I know any dialysis access is not up for grabs, but in a code situation is there any way to use it emergently and safely?

What about the central line looking tubes with blue and red caps?

I'm talking when it's either endotracheal drugs or a Jamshidi needle, not just a difficult IV stick. If we do take the risk and access a fistula how do we deaccess safely? Is this an arterial access? Does it need to be heparinized?

How many Hail Marys should I do in penance before confessing my sins to the dialysis RN?

NO I haven't had to do it yet, but I've sure eyed those sites like a hungry vampire.

[DeLana_RN, BSN, RN]

A doctor's order will allow you to use a dialysis access, especially in an emergency. But even floors and ICUs often use permcaths (the double-lumen central lines you mentioned) if they have trouble placing a peripheral IV or PICC. A clave port may be attached, but you can access the lumens with any syringe. 100:1 heparin is usually instilled q shift; usually, there is an order set outlining this. Again, this requires a doctor's order.

If the CVC has no special port cap attached, as it probably won't in the ER, you need to first waste about 3 cc of blood/heparin; then flush the lumens with 10 cc NS. After use, keep a syringe attached and make sure the lines are securely clamped. Usually, you would flush the lines with 10-20 cc NS and then instill 2.5 cc 1000:1 heparin; then attach the special port caps (you may need a dialysis nurse for this.)

If you need to access a fistula (native vessel) or graft, yes this is an arterial access; however, it can be cannulated like any vein. I would use a large-bore butterfly needle or a fistula needle if you can get it. Heparin is only needed for dialysis to prevent clotting in the system. When done, you can just remove the needle and hold pressure until bleeding stops (usually just a few minutes); then apply a pressure bandage (folded gauze).

Perhaps your ER could obtain a standing order set for dialysis access use from nephrology for such emergency situations.

DeLana

[canoehead, BSN, RN]

So a central line type access is not usually an arterial site? We often see lines with blue and red caps and I assumed those indicated arterial or venous flow.

[km5v6r, EdD, RN]

So a central line type access is not usually an arterial site? We often see lines with blue and red caps and I assumed those indicated arterial or venous flow.

The tip of that catheter sits in the same place; the Vena Cava (superior or inferior) or the Rt Atrium. In dialysis the port that pulls blood from the pt to the machine is refered to as the arterial side and has a red end or cap. The blue is the port that blood is returned to the pt through and is refered to as the venous side of the tubing or catheter. The signficance come in with the end of the catheter. The red lumen is generally shorter then the blue lumen and terminates with holes on the side of the catherer proximal to the end. The blue lumen generally has holes at the tip of the catheter. During dialysis blood is pulled from and returned to the body at the same time. Two seperate lumens with different termination points helps to reduce the amount of recirculation that occurs. The goal is to pull the blood "upstream" from where it is returned. We would ask if the catheter had to be accessed for IV's or blood draws that the blue or venous port be accessed. The additional accessing will "gunk" up a line. It is much easier to push blood back through the port with the "gunk" then it is to pull blood from the "gunked" port. You will get only venous blood either way. Hope this helps.

[canoehead, BSN, RN]

Wow, that is so helpful. It sounds like dialysis catheters should be OK to access for meds, but cannot be used during dialysis, is that correct?

And a fistula would be the same as infusing meds into an artery, and should never be done (unless the pt is actually dead with no access, then anything goes?)

I really appreciate this, dialysis has been shrouded in such mystery that we did not touch their stuff no matter what. Some of us just have to know what's going on behind the curtain. :)

[km5v6r, EdD, RN]

Wow, that is so helpful. It sounds like dialysis catheters should be OK to access for meds, but cannot be used during dialysis, is that correct?

Prefered is to not access the dialysis catheter except for dialysis. The more times it is accessed the high the risk for infection and clotting of the line. An order to access the line can only come from the Nephrologist. No other physician can OK using the line. Special care also has to be taken to remove the Heparin and reload it after treatment. We used to use Heparin 5000 units/ml and a volume of 1-3 ml depending on the catheter.