dialysis patients and iv access

[njmedic1485]

We are allowed to access AV shunts as an absolute last resort (medical control option) access, we carry the same needless that the dialysis centers use and include the procedure in our yearly education/skills day. I've done them a couple of times but only during codes. The dual port subclavian ports they put in as temporary accesses until the grafts cure are much better. Just aspirate 5 ml and waste then flush with saline and your good to go. And yes our nephrologists go ape sheet when we access them.

For the uninitiated an AV shunt or graft is a goretex tube that joins a vein and artery in a patients arm. After the graft is in place it needs to "cure for 6 to 8 weeks, this allows a layer of epithelial cells (I'm pretty sure I misspelled that) to grow over the graft, that cell layer is what clots off after being punctured. To assess a graft for patency; palpate and auscultate, you should feel a definite pressure difference even in shock states (not so much in cardiac arrest) and you should hear a nice loud bruit. We are taught not to stick on the loop of the graft and to avoid any recent sites, our insertion angle is steeper then a regular IV stick then you rotate the needle 180 degrees and flatten your angle as you advance the needle into the graft. This is supposed to stop you from going thru the graft.

[Camulos]

how about the hagen formula

The larger the catheter the more fluid that can go thru the cath into the body.

a 22 ga will give x amount while a 14ga will give a lot more.

I'm not sure of the actual formula numbers.

Hagen-Poiseuille equation

GOLD star to Ruffems!!!! Well done. :hello1:

The application of this equation can get pretty advanced. However when you nut it all out it is basically saying the shorter and fatter a tube, or IVC, is - the greater the flow. So basically, in trauma don't insert a LONG THIN central line. Insert a SHORT FAT 14G IVC

Stay safe,

Curse :evil:

[JPINFV]

The application of this equation can get pretty advanced. However when you nut it all out it is basically saying the shorter and fatter a tube, or IVC, is - the greater the flow. So basically, in trauma don't insert a LONG THIN central line. Insert a SHORT FAT 14G IVC

Isn't the gist of that formula kinda of a priori knowledge?

[Camulos]

Isn't the gist of that formula kinda of a priori knowledge?

To be entirely honest I'm not sure what you really mean by this. Don't get me wrong I understand the words, but just dont really understand what your overall feelings on this theory are. As such, I would appreciate if you could provide more info here.

Stay safe,

Curse :evil:

[IndianaEMT81]

Our local protocols are pretty much against the use of either the fistulas or the grafts. We have to go throught medical control to get authorization to even try. Our area is warming up to IO's being used more and more and not just for pediatric pt's. Critical pt's are given a couple attempts at IV access then we don't hesistate to go to our EZ IO's.

In my medic class we had a very good presention from a dialysis nurs explaining why they don't like anyone to access the either of the dialysis sites:

In the case of the permcaths the thinking was that some people don't realize that there is heparin in the lines and a flush would push an excess of heparin into the pt's system.

With the grafts, there is a very high risk of infection. So they would just rather avoid that all together.

Like I said though, I'm still a medic student and this is what I learned haven't had any critical dialysis pt's in the field yet. However, during my in hospital time, most of the dialysis pt's that needed an IV I was able to find a suitable vein and place one unless they had other major health problems that caused a lack of good potential IV sites.

Don't know if this helps but this is what I've noticed in my area.

[Camulos]

Anyone ever performed or been witness to a venous cutdown in the field?

Stay safe,

Curse :evil:

[JPINFV]

Isn't the gist of that formula kinda of a priori knowledge?

To be entirely honest I'm not sure what you really mean by this. Don't get me wrong I understand the words, but just dont really understand what your overall feelings on this theory are. As such, I would appreciate if you could provide more info here.

Stay safe,

Curse :evil:

[p3medic]

Anyone ever performed or been witness to a venous cutdown in the field?

Stay safe,

Curse :evil:

I've done them on anesthetized goats in ATLS , but never seen it done in the field or ED. With I.O. devices readily available and very quick to use, I think cut downs for emergent vascular access has fallen out of favor, but I could be wrong.

[crotchitymedic1986]

Here is crotchity's law:

Dont poo-poo my 22, when you have nothing for fluid to travel through.

Is a 22 ideal ? No, but is it better to have a successful 22 in that little vein, or an unsuccessful 18 in that one little vein.

On another educational note:

The superficial dorsal vein of the penis is always there, and easy to find. But if you cannulate that vein, you flunk the "Baptist Heaven Entry Test", and will spend eternity in hell.

[spenac]

Here is crotchity's law:

Dont poo-poo my 22, when you have nothing for fluid to travel through.

Is a 22 ideal ? No, but is it better to have a successful 22 in that little vein, or an unsuccessful 18 in that one little vein.

On another educational note:

The superficial dorsal vein of the penis is always there, and easy to find. But if you cannulate that vein, you flunk the "Baptist Heaven Entry Test", and will spend eternity in hell.

Why not go under the tongue?

Heck how about you get a emt life? :twisted: I have heard some at another site are having fun with your presence.

Now I have started a small IV such as 22 or even 24 then was able to expand vein and Place a large bore. Central lines are part of the service I am at today. So not really a problem getting access.