Reference — Renal
Dialysis Access Devices Reference
Hemodialysis access devices — AV fistula, AV graft, tunneled CVC, and temporary CVC: assessment, complications, and nursing safety priorities.
Educational use only. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Access is a lifeline. For dialysis patients, vascular access is literally life-sustaining. Protect all AV access — never use the fistula/graft arm for BP, IV, or blood draws under any circumstances.
AV Fistula
GOLD STANDARD — preferred access for long-term hemodialysis
Surgical creation of a direct connection (anastomosis) between an artery and a vein — most commonly the radial artery and cephalic vein in the non-dominant forearm. The increased arterial flow causes the vein to enlarge (mature) and develop thickened walls suitable for repeated needle access.
Characteristics
Assessment Priorities
- ✦Auscultate bruit (continuous whooshing sound) with stethoscope at access site — should be present
- ✦Palpate thrill (vibration, buzzing feel) over anastomosis — should be present
- ✦Inspect skin overlying fistula for redness, warmth, swelling, or drainage
- ✦Assess extremity distal to fistula for pulses, temperature, sensation (steal syndrome risk)
- ✦Ask patient about arm pain or cold/numb fingers (steal syndrome)
Complications
| Complication | Signs/Symptoms | Nursing Action |
|---|---|---|
| Thrombosis (clotting) | Loss of bruit and thrill | Notify provider immediately; urgent thrombectomy within hours |
| Steal syndrome | Hand coldness, pain, numbness distal to access — blood "stolen" from distal circulation | Notify provider; may require ligation or banding procedure |
| Aneurysm | Focal bulging/dilation of fistula; may be normal maturation vs true aneurysm | Monitor; report new or enlarging aneurysm |
| Infection | Redness, warmth, drainage — less common than CVC | Culture; antibiotics; rarely requires surgical intervention |
| Failure to mature | Vein does not enlarge sufficiently for needle access within 12 weeks | Evaluation for intervention (balloon angioplasty) or alternative access planning |
Nursing Safety Priorities
- ⚠NEVER take blood pressure in the fistula arm
- ⚠NEVER draw blood from the fistula arm
- ⚠NEVER start peripheral IV in the fistula arm
- ⚠Do not apply constrictive clothing, jewelry, or blood pressure cuff to fistula arm
- ⚠Teach patient to sleep with arm unconstrained
- ⚠Apply pressure 15–20 minutes after needle removal post-dialysis
AV Graft
Second-line access — used when vessels are inadequate for fistula
A synthetic tube graft (typically PTFE — polytetrafluoroethylene) is surgically implanted to connect an artery to a vein when the patient's own veins are insufficient for AV fistula creation. The graft provides a durable surface for repeated needle cannulation.
Characteristics
Assessment Priorities
- ✦Palpate graft along its course — should feel soft, compressible (not hard/cord-like)
- ✦Auscultate bruit over graft — should be continuous
- ✦Palpate thrill at graft — should be present
- ✦Inspect skin for infection signs — grafts have higher infection risk than fistulas
- ✦Note any pseudoaneurysm formation (bulging at needle sites)
Complications
| Complication | Signs/Symptoms | Nursing Action |
|---|---|---|
| Thrombosis | Loss of bruit and thrill; graft feels cord-like | Notify provider immediately; declot procedure within hours |
| Infection | Erythema, warmth, swelling, purulent drainage, fever | Culture; antibiotics; graft removal may be required for tunnel infection |
| Pseudoaneurysm | Focal bulging at repeated needle access sites | Monitor size; avoid cannulating pseudoaneurysm; report new/enlarging |
| Steal syndrome | Same as fistula — hand coldness, pain | Notify provider |
Nursing Safety Priorities
- ⚠Same arm restrictions as AV fistula — no BP, no IV, no blood draws
- ⚠Do NOT access graft for non-dialysis IV use
- ⚠Apply pressure post-dialysis — grafts may bleed longer than fistulas
- ⚠Teach patient to report warmth, swelling, or fever around graft
Tunneled Central Venous Catheter (CVC)
Used when AV access is not possible or as bridge while AV access matures
A double-lumen silicone or polyurethane catheter tunneled subcutaneously before entering the central vein (typically right internal jugular vein). The Dacron cuff at the tunnel exit site creates a bacterial barrier and anchors the catheter. Examples: Permcath, Quinton catheter.
Characteristics
Assessment Priorities
- ✦Inspect exit site for redness, swelling, drainage, cuff extrusion
- ✦Assess for fever, chills — signs of catheter-related bloodstream infection (CRBSI)
- ✦Verify catheter position (chest X-ray after placement)
- ✦Check clamps are closed when not in use
- ✦Assess for tunnel infection (tenderness along tunnel track under skin)
Complications
| Complication | Signs/Symptoms | Nursing Action |
|---|---|---|
| Catheter-related bloodstream infection (CRBSI) | Fever, chills, hypotension — can progress to sepsis | Blood cultures x2 (one from catheter, one peripheral); antibiotics; catheter removal if tunnel infected |
| Thrombosis / poor flow | Unable to withdraw blood or infuse; slow blood flow during dialysis | Thrombolytics (tPA) per protocol; notify provider |
| Catheter exit site infection | Redness, drainage, tenderness at exit site only (not tunnel) | Local wound care; antibiotics; monitor for progression |
| Catheter dislodgment | Visible catheter lengthening; unexpected position | Do NOT use catheter; notify provider; chest X-ray to confirm position |
Nursing Safety Priorities
- ⚠Tunneled CVCs are for dialysis use ONLY — do not use for IV medications or other access
- ⚠Maintain aseptic technique during all catheter manipulations
- ⚠Keep clamps closed at all times except during dialysis
- ⚠Change dressing per protocol — typically 1–2 times/week and when soiled
- ⚠Use masks for patient and nurse during any catheter access (reduces airborne contamination)
Temporary (Non-Tunneled) CVC
Emergency use only — short-term bridge to definitive access
A non-tunneled double-lumen catheter inserted directly into a central vein (IJ, subclavian, or femoral) for emergent dialysis access. No subcutaneous tunnel or Dacron cuff — placed at bedside or in procedure room.
Characteristics
Assessment Priorities
- ✦Monitor insertion site closely for infection — daily inspection
- ✦Check for fever and systemic signs of infection
- ✦Ensure catheter is secured to prevent accidental dislodgment
- ✦Confirm tip position with CXR after IJ or subclavian placement
- ✦Monitor blood flow rates during dialysis — may be suboptimal
Complications
| Complication | Signs/Symptoms | Nursing Action |
|---|---|---|
| Infection (highest risk of all access types) | Exit site infection, tunnel infection (no tunnel but direct track), CRBSI, sepsis | Remove catheter as soon as permanent access available; antibiotics; cultures |
| Pneumothorax (subclavian/IJ insertion) | Decreased breath sounds, dyspnea, chest pain post-insertion | Immediate CXR post-placement; oxygen; chest tube if significant |
| Accidental dislodgment | Catheter pulled out; uncontrolled bleeding | Apply pressure; call for help; emergency response |
Nursing Safety Priorities
- ⚠Convert to permanent access or tunneled CVC as quickly as possible
- ⚠Do not use for routine IV access
- ⚠Strict aseptic technique — no tolerance for technique breaks
- ⚠Femoral catheters: strict bedrest; daily site inspection; remove as soon as possible
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with KDIGO Clinical Practice Guidelines · National Kidney Foundation (NKF). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →