Dialysis and the Access

07/05/13:  Reposted of the original 6/30/13 posting

I’ve accumulated some information over the past several months about Dialysis and the Access; the A/V Fistula, the A/V Graft, and the Dialysis Catheter.  (This was originally published on 6/30/13 and I’ll leave it up for a few days. )

Dialysis Access Information

I searched for a good reference site about each dialysis access option and found… not much.  Many attempt to explain the access from a medical point of view.  That’s unnecessary.   So, here they are and some quick information about each:

1 – The AV Fistula.  This is the result of joining an artery and vein together surgically to provide a place to stick the dialysis needles.  It’s the preferred method but it requires that the access “matures” and that takes anywhere from 3 to 6 months.

2 – The A/V Graft.  Similar to the Fistula in that it must be surgically installed, it’s a synthetic tube placed under the skin and this is where the dialysis needle will be inserted.   A graft is particularly suited to patients with small veisn and the elderly patient (as mentioned in the studybelow).

3 – Catheter.  This is a set of tubes inserted surgically into an artery and vein.   The tubes are outside the chest (usually) but can also be located in the neck or groin.  Most often this is the method used so that a patient can begin dialysis immediately as it requires no healing (or maturing) like the A/V Fistula and Graft.  It’s considered a temporary access to be replaced by a fistula or graft.

For what it’s worth, I found this website that has a good, simple explanation of the three methods but they, like others, insist on using medical terminology to describe them.  Anyway, the pictures are good.  CLICK HERE to read it.

Lidocaine

I wrote previously about my A/V Fistula access and my experience with Lidocaine.  Here’s a link to that post.  If you’re considering Lidocaine injections thinking that will ease the pain, my experience is that it causes scarring and makes it difficult to stop bleeding after the needle is removed.  Also, the pain of the Lidocaine injection is much worse than the cannulation (the needle stick).

I also got this comment that appears below but it’s important enough that I copied it here…

Devon, though I also think the lidocaine shots aren’t worth the pain (and scarring they cause) have you tried the lidocaine/prilocaine (aka Emla) cream? It’s placed on top of the needle site at least 1 hour before (I personally do 2 hours before) dialysis. It numbs the area where the stick is going to occur.

I find that if you are doing a buttonhole access, and the nerves you’re inserting past are not dead yet, this significantly lowers the amount of pain. For the longest time (3+ years) the venous insertion ALWAYS hurt since the hole was right on top of a nerve. Without the cream, this was an insertion that had me screaming in pain, but with the cream it went down to a grimace but I could bear the pain.

Now, if you are using sharp dialysis needles and not buttonhole, this cream may not help as much since it’s a topical application and only numbs the area where it is applied. Also, it is VERY IMPORTANT that you cover the area where you applied the cream with an _airtight_ seal of some sort. Lido/Prilo will not work until it is in an airtight environment. Some people use saran wrap (though it looks silly) but I personally use 3M’s Tegaderm. It’s expensive but I know the seal it creates is airtight. The cost of the Lido/Prilo cream, without insurance, is pretty expensive so I’d want to make sure any I’m applying is effective.

Another thing I’ve noticed with using this cream (and I’ve used it since I started dialysis) is that you want to apply enough that there is a little bit still left just before they begin to stick you. Once the cream is removed, the numbness will wear off fairly quickly so you want to make sure that they don’t remove it till they’re ready to stick you.  Accordingly you want to make sure that the cream isn’t  fully absorbed before they’re ready to stick you otherwise you might as well have not have applied it.

Since it is a cream, that means that it’ll move around a little bit under the cover you applied (be it tegaderm or saran wrap). Because of that it has a tendency to want to “clump” all together. I usually check it routinely (every 15 to 30 min) to make sure it’s applied to the needle site evenly.

I made a couple of example images (without using cream) to kind of show how it’s applied.

First this is what my Fistula looks like:
http://shell.melodybliss.org/~melody/pics/dialysis/fistula/melody-av_fistula.jpg

This is how I apply the lido/prilo cream:
http://shell.melodybliss.org/~melody/pics/dialysis/fistula/melody-lpcream.jpg

The little circles is where I apply little “drops” of the cream. The cream comes in a 30 gram tube. One tube lasts me about 2 weeks, so 5 grams approx per application (aka dialysis). I use 2 tubes per month. You end of using ALOT of cream in the beginning as you learn the right amount for you.

The outer squarish box is where I place the tegaderm so it’s all covered. I make sure the tegaderm is flush against my skin and no air bubbles have occurred. I then push the tegaderm against the cream to even it all out and to make sure the needle sites themselves are covered.

Thank you for that “MelodyBliss”!

Discussion

In a discussion about Peritoneal Dialysis and Home and In-center Hemodialysis, here are some responses I gave to friends that were going through the first few weeks of dialysis…

I know things must seem overwhelming right now.  Frankly, they are!  There is so much information to go through and digest.  You’re doing very well though.  Better than most people.

Your experiences with the new fistula are typical.  As it develops and matures. it will get those sounds more and more. And, yes, you can hear it when you sleep.  Keep in mind that this fistula is your access to dialysis and it’s VERY important to take good care of it.  Keep it clean.  Wash it with anti-bacterial soap before dialysis.  Treat it tenderly.  If it fails, you have to go through all this over again.  A fistula can last for years if all goes well.

Check your fistula periodically for the Rush and Thrill,  the sounds it makes for the venous and arterial flows.  If you hear it whistling, that means it is not flowing correctly.  To recognize those sounds takes an experience ear.  The nurse should be able to help but keep in mind that not everyone is experienced.  I make sure a couple people check it over a week or so just to be sure.  A problem is not going to happen right away generally.  It take a while.  Listen for changes. especially a whistling sound which means there is a blockage in the access.

It takes a couple months for the fistula to mature before it can be used.  The first few sticks will probably be difficult.  I had a rough time as you probably know from the article, “Dialysis and the First Stick“.   But everything works out eventually and now I’m a “pro”.  LOL.  You can use Lidocaine cream and Lidocaine injections for the first months but wean yourself off those.  After being stuck a few times without them, you actually can’t feel anything but some discomfort.  I only feel it when they are not sticking it in the right place.

If you’re going to do PD (Peritoneal Dialysis) or Home Hemodialysis, you need a sterile environment at home and a helper.  I couldn’t do it with (at the time) with two dogs and a cat.  I’m down to one dog and a cat but I still don’t see it in the immediate future.  That may change, who knows.  Personally, I enjoy the activity at the center even if I don’t enjoy having to get there and some elements of it such as the crappy TVs and slow WiFi.  But, I’m working to change that.   I’m sure I’m a pain in their side but that’s my “job” as a Patient Rep.  I was meant to do that kind of work.  If I could, I probably would do PD or home hemo.  I hope that works well for you.

A Recent Study

A recent study that involved elderly folks posed the question of what access was better for them.  They looked at the A/V Fistula, the Catheter, and a Graft and determined that the graft was probably better in older patients (over 70) because it was better in the case of smaller veins, was ready quicker than a fistula, and required less care than a catheter.  You can read about it by CLICKING HERE.

© 2013 DevonTexas

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About DevonTexas

I am a person with ESRD (End Stage Renal Disease) which means my kidneys don't work. Forty or so years ago that would have been a death sentence but today there is Dialysis which means I can be hooked up to a machine that will clean my blood as the kidneys should. Three days a week, I go to a center and have too very large needles stuck in my arm to remove and replace my blood as it passes through a process where it's cleaned and the fluid is removed, a process taking a little over four hours each time. I want to advance knowledge about dialysis so that other patients can learn from my experience and mistakes. We shouldn't have to reinvent the wheel, eh? There is so much to be learned and experienced about our predicament. There are vast resources available to support us and enrich our lives but many patients don't know about them. There are also many issues that we have to deal with whether we want to or not. So I blog about them. All comments are confidential until I approve them. If you don't want your comment public, let me know and I will respect that. So, feel free to leave a comment. Enjoy.
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10 Responses to Dialysis and the Access

  1. melodybliss says:

    Devon, though I also think the lidocaine shots aren’t worth the pain (and scarring they cause) have you tried the lidocaine/prilocaine (aka Emla) cream? It’s placed on top of the needle site at least 1 hour before (I personally do 2 hours before) dialysis. It numbs the area where the stick is going to occur.

    I find that if you are doing a buttonhole access, and the nerves you’re inserting past are not dead yet, this significantly lowers the amount of pain. For the longest time (3+ years) the venous insertion ALWAYS hurt since the hole was right on top of a nerve. Without the cream, this was an insertion that had me screaming in pain, but with the cream it went down to a grimace but I could bear the pain.

    Now, if you are using sharp dialysis needles and not buttonhole, this cream may not help as much since it’s a topical application and only numbs the area where it is applied. Also, it is VERY IMPORTANT that you cover the area where you applied the cream with an _airtight_ seal of some sort. Lido/Prilo will not work until it is in an airtight environment. Some people use saran wrap (though it looks silly) but I personally use 3M’s Tegaderm. It’s expensive but I know the seal it creates is airtight. The cost of the Lido/Prilo cream, without insurance, is pretty expensive so I’d want to make sure any I’m applying is effective.

    Another thing I’ve noticed with using this cream (and I’ve used it since I started dialysis) is that you want to apply enough that there is a little bit still left just before they begin to stick you. Once the cream is removed, the numbness will wear off fairly quickly so you want to make sure that they don’t remove it till they’re ready to stick you. Accordingly you want to make sure that the cream isn’t fully absorbed before they’re ready to stick you otherwise you might as well have not have applied it.

    Since it is a cream, that means that it’ll move around a little bit under the cover you applied (be it tegaderm or saran wrap). Because of that it has a tendency to want to “clump” all together. I usually check it routinely (every 15 to 30 min) to make sure it’s applied to the needle site evenly.

    I made a couple of example images (without using cream) to kind of show how it’s applied.

    First this is what my Fistula looks like:

    This is how I apply the lido/prilo cream:

    The little circles is where I apply little “drops” of the cream. The cream comes in a 30 gram tube. One tube lasts me about 2 weeks, so 5 grams approx per application (aka dialysis). I use 2 tubes per month. You end of using ALOT of cream in the beginning as you learn the right amount for you.

    The outer squarish box is where I place the tegaderm so it’s all covered. I make sure the tegaderm is flush against my skin and no air bubbles have occurred. I then push the tegaderm against the cream to even it all out and to make sure the needle sites themselves are covered.

  2. Sara says:

    I plan to start PD at my home at end of July. I’m not clear–do you do PD at a clinic?

    • DevonTexas says:

      PD (Peritoneal Dialysis) is usually done at home. It could be done in the clinic but I’ve not seen where that is offered. It’s a great method because it allows you to do it on your schedule and more often than three days a week. However, I cannot stress how important ti s to keep a sterile environment and procedures. Far too often PD results in serious infections that result in hospitalization usually due to peritonitis (an infection of the peritoneum). Keep that site clean and sterile!

      It’s interesting that I got your comment becuse I was just working on a post about the treatment options of which PD is one. Thank you for this comment!

  3. There’s also a rather new form of access called a HeROGraft which is a kind of combination between a graft & a catheter.It still goes in the heart like a catheter but instead of hanging the line outside,it is tunneled under the skin on the upper arm as a graft & is accessed by cannulation.

  4. Deveon this is a great blog!! I am a dialysis patient. (ESRD in 2011) I have done both in-center Hemo and currently on PD. For me PD is better because I have a fear of needles and anyone on Hemo knows those needles are nothing but deadly…. I have really enjoyed reading your posts and we be back in the future.

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