CE: continuing education article. Integration of palliative care for patients with stage 5 chronic kidney disease.

Patients with advanced chronic kidney disease (Stage 5 CKD) have palliative care needs similar to patients with cancer. The decision not to commence dialysis or to withdraw from active treatment can have a profound impact upon all those closely involved in the patient's care. It is essential that every effort is made to minimise the physical and psycho-social symptoms experienced by patients who require palliative care. Effective teamwork across professional boundaries and specialities will ensure that patients and their families are provided with maximum comfort during their final days. All members of the healthcare team must strive to ensure patient and family are actively encouraged in the decision-making process surrounding palliative care needs.

Vascular access management III: central venous catheters.

This third article, the final part of a Continuing Education (CE) series on Vascular Access Management for patients with end stage renal disease (ESRD), focuses on central venous catheters. CVCs are considered the last choice in vascular access due to the numerous complications associated with their use. This CE article explores the incidence and prevalence of central venous catheters within the context of international guidelines, type and design of central venous catheters, insertion procedure, strategies for preventing infection and complications associated with their use.

Vascular Access Management II: AVF/AVG cannulation techniques and complications.

This second article, in a three-part Continuing Education (CE) series on Vascular Access Management, focuses on cannulation issues including complications relating to arteriovenous fistula and arteriovenous graft access. The first article (McCann et al. 2008) gave an overview of vascular access while the final article in this series will focus on central venous catheters (CVC).

Venous needle dislodgement: how to minimise the risks.

Although haemodialysis (HD) has become a routine treatment, adverse side effects, and occasionally life threatening clinical complications, still happen. Venous needle dislodgment (VND) is one of the most serious accidents that can occur during HD. If the blood pump is not stopped, either by activation of the protective system of the dialysis machine or manually, the patient can bleed to death within minutes. Fatal and near-fatal blood loss due to VND have been described in the literature (ECRI 1998; Sandroni 2005; Mactier & Worth 2007), but published reports represent only the tip of the ice berg, as such incidents are normally handled at a local or national level. The European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA) has produced 12 practice recommendations to help reduce the risk of VND and detect blood leakage as early as possible. A poster summarising these recommendations has been created (Van Waeleghem et al. 2008).

Vascular access management 1: an overview.

Vascular access for renal replacement therapy (RRT) is seen as one of the most challenging areas confronting the nephrology multidisciplinary team. The vascular access of choice is the arterio-venous fistula (AVF) followed by the arterio-venous graft (AVG) and central venous catheter (CVC). A successful vascular access programme requires forward planning ensuring that enough time is available for the preservation of the access site, its creation and maturation. Successful cannulation of the vascular access requires on the part of the nephrology nurse, clinical expertise and knowledge on the management of different types of vascular access including different cannulation techniques.

EDTNA/ERCA vascular access recommendations for nephrology nurses.

In 1989, SJ. Schwab stated that providing satisfactory vascular access for haemodialysis remains one of the most challenging problems confronting the nephrology team (1). Successful long-term haemodialysis in patients with end-stage renal failure depends to a large extent upon a trouble-free vascular access. Unfortunately, the creation as well as the use, maintenance and the treatment of vascular access complications nowadays still remain a serious clinical problem despite pharmacological and technical advances during the last decade (2). Even today, vascular access failure and complications form a major cause of morbidity leading to a high percentage (20 to 30 %) of hospitalization in the dialysis population (3). Moreover, we are confronted all over the world with a clinically complicated patient population, such as diabetics, patients with advanced atherosclerosis, cardiac and peripheral vascular diseases. Also the increased blood viscosity due to the systematic use of erythropoietin and the use of high blood flows in modern dialysis therapy necessitates a vascular access of excellent quality.

Complications of vascular access: results of a European multi centre study of the EDTNA/ERCA Research Board.

The pilot project of the Research Board of EDTNA/ERCA handled the management of vascular accesses (VA) in European dialysis centres. In the first part of the study, centre policies related to VA management were investigated. In the second part of the study, individual patients were followed prospectively during one year. This paper reports on several topics of the second part of the project, investigating complications of the VA related to centre, patient characteristics and dialysis techniques used. Complications most frequently observed were thrombosis, stenosis, infection, bleeding and flow problems. Gradually more infections and flow problems were observed if the centre size and the patients/nurse ratio went up. Complication rate was not significantly influenced by age, gender, renal diagnosis, time on dialysis or medication used by the patient. In contrast, the number of vascular accesses in the past and interventions in the VA before first use resulted in an increased number of complications. Nurses have a key role in the prevention, manipulation and outcome of vascular access related complications.

Identifying vascular access complications among ESRD patients in Europe. A prospective, multicenter study.

The pilot project of the Research Board of the EDTNA/ERCA was aimed at reviewing the management of vascular access (VA) in European dialysis centres (see August 1999 NN&I). In Part 1 of this study, centre policies related to VA management were investigated. In Part 2, detailed in this article, individual patients were prospectively followed for one year to identify VA-related complications. A cohort of 1,380 adult patients randomly selected from 47 centres in 16 European countries was followed for one year using a computerised data collection system. Data were collected at baseline after 6 and 12 months and each time a VA complication occurred. At the start of the observation period, 77% of patients had a native arteriovenous (AV) fistula, 10% had an AV graft, and 13% had a catheter for access. A total of 489 complications were noted during the one-year period. Most frequently observed were thrombosis, stenosis, infection, bleeding, and flow problems. Hospitalisation (mean duration = 6.2 days) was required in 39% of patients with complications, and 29% of complications resulted in a definitive loss of VA. Complications were more frequently observed in patients with catheters (27%) and AV grafts (37%) compared to those with an AV fistula (15%). The risk of thrombosis was more than four times higher and the risk of bleeding was more than six times higher if an AV graft was used compared to an AV fistula. Catheters presented an eightfold increased risk for patients of developing infections and access flow problems. [figure: see text] This study revealed the high complication rate in VA and strengthened the notion that the AV fistula is the superior access.