Fistula Puncture Site Research Articles

Evaluation of the pain scale during arteriovenous fistula puncture with and without lidocaine gel 2% in patients undergoing haemodialysis in Kosovo

Aimthis study aims to evaluate the pain scale during Arteriovenous fistula (AVF) puncture in patients undergoing regular haemodialysis sessions with and without Lidocaine gel 2%. MethodsThe study is Cross-Sectional, conducted at the University Clinical Centre of Kosovo - Clinic of Nephrology and Haemodialysis in Pristina, Regional Haemodialysis Centre in Prizren, Regional Haemodialysis Centre in Gjilan and Regional Haemodialysis Centre in Mitrovica, all in Kosovo. In this research, 616 patients were surveyed during AVF puncture and the other group of 232 patients in whom 2% Lidocaine gel was applied before puncture at the fistula puncture site. ResultsIn the above mentioned centres, the total number of patients who are on dialysis through AVF is 632, of which 324 men and 308 women. 560 patients had created AVF on the left arm and 72 patients on the right arm. In our research, 616 patients were surveyed, of which 312 men and 304 women. The most affected age group was between 60 and 69. The pain scale reported during AVF punctuation was moderate in 304 (49%) patients, severe in 176 patients (29%) and mild in 136 (22%) patients. After the applying of Lidocaine gel 2%, the puncture of AVF was performed, so from the total number of 232 participants, 64 (28%) of them reported moderate pain and 168 (72%) of research participants reported mild pain during puncture of AVF. In order to compare results from both groups, we have chosen a random sample from the first group during AVF punctuation without Lidocaine gel 2% (234 in total from 616 patients) and compared the result with the second group during AVF puncture with Lidocaine gel 2% (232 in total). ConclusionsThe average pain scale during AVF puncture without Lidocaine gel 2% was 5.04 while the average pain scale after applied Lidocaine gel 2% was 2.61.

Cutaneous necrosis of the arteriovenous fistula puncture site in chronic hemodialysis: A historical complication or an ever-present threat? A series of 26 cases.

Cutaneous necrosis (CN) at the puncture site of the arteriovenous fistula (AVF) in chronic hemodialysis (CHD) is a rare but potentially fatal complication. The objective of our work was to establish the associated complications, vascular prognosis, and patient survival of CHD patients presenting cutaneous necrosis. This retrospective study (January 2016 to March 2020) was conducted in the Department of Vascular Surgery and the Department of Nephrology at the University Hospital Center Mohammed VI of Oujda, Morocco. Included were all CHD patients admitted for treatment of cutaneous necrosis at the puncture site of a native AVF. Data from 26 cases were collected. The mean age was 58.7 ± 16 years, 70.8% were female, and 25% had diabetic nephropathy; 42.3% of the AVFs were radiocephalic and 46.1% were brachiocephalic; 42.2% of patients presented active bleeding, of whom 91% required a blood transfusion; 80.8% of the AVFs were complicated by aneurysms. Fistulography showed stenosis in 42.3% of cases. Urgent surgical intervention was performed on all the patients. Fifty percent of patients required placement of a short-term hemodialysis catheter. Two patients had presented a recurrence. Death occurred in one case following a massive hemorrhagic shock. Cutaneous necrosis is a relatively common complication and requires early screening and immediate surgical intervention.

Prolonged Bleeding Following Removal of Arterio-Venous Fistula Needles after Hemodialysis Therapy

Background: Bleeding at fistula sites in patients with end stage renal disease (ESRD) is a common and potentially serious complication that contributes to blood loss (anemia). This study aimed to determine the factors that influence prolonged bleeding at fistula puncture sites following removal of fistula needles.Methods: This was a descriptive cross-sectional study. We consecutively enrolled patients who underwent maintenance hemodialysis between May and October 2017 at Muhimbili National Hospital and Access Dialysis Centre in Dar es Salaam, Tanzania. A case report form (CRF) was used for data collection.Prolonged bleeding was assessed by measuring activated partial thromboplastin time (aPTT) and compression time (CT). Descriptive statistics and regression analysis were used to assess the association between factors and tease out the independent factors associated with prolonged bleeding at fistula puncture site. A two-tailed p-value <0.05 was used as a cut-off for statistical significance.Results: One hundred and fifteen patients were recruited for the study whereby 81(70.4%) of participants had elevated aPTT (> 31 seconds) and 4 (3.5%) had prolonged compression time (> 15 minutes). The mean aPTT and compression time of the participants were 42 ± 17.6 seconds and 5 ± 2.9 minutes respectively. Over half of participants 67(58.2%) had normal compression time (≤ 15 minutes). Elevated serum urea levels (> 7.4mmol/L) was the only factor significantly associated with elevated aPTT (OR=4.143 95% C.I (1.021-16.810), p=0.047).Conclusion: The findings have demonstrated that elevated serum urea levels are significantly associated with prolonged bleeding time following removal of Arterio-Venous fistula needles after completion of a hemodialysis therapy session. This study suggests that, in hemodialysis procedure where a fixed dose of heparin is generalized to all patients there is a chance of exceeding the individual’s requirements.Recommendations: Serum urea levels should be factored in when gauging the individual risk of arterio-venous fistula site bleeding for patients using heparin for anticoagulation during hemodialysis. Further studies with large sample sizes are recommended to elucidate how other predisposing factors may affect A-V fistula bleeding.
 Keywords: Hemodialysis, heparin, prolonged bleeding, urea reduction ratio, A-V Fistula, aPTT, Compression time, blood urea.

Assess the effectiveness of cryotherapy on arterio Venous fistula puncture site pain among Patients on haemodialysis

Assess the effectiveness of cryotherapy on arterio Venous fistula puncture site pain among Patients on haemodialysis

A Project to Reduce the Occlusion Rate in Hemodialysis Arteriovenous Access

Vascular occlusions in patients frequently necessitate that duty nurses work overtime to manage related vascular problems. For patients, vascular occlusions require invasive treatments that are painful, take time to heal, and increase anxiety. Furthermore, vascular occlusions seriously influence the effectiveness of hemodialysis. This project worked to reduce the rates of occlusion from 18.6% to < 15% for hemodialysis arteriovenous grafts (AVGs) and from 5.2% to < 2.6% for arteriovenous fistulas (AVFs). This project was conducted between September 1st, 2012 and July 31th, 2013. Our approach used a retrospective study, literature review, meeting discussions, and data compilation. The four main problems identified as associated with occlusion were: (1) low blood pressure during hemodialysis; (2) successive fistula puncture sites were located too close to one another; (3) abnormal blood flow; and (4) poor moisture control. Our solutions included: 1) adjusting and creating forms; 2) adjusting related nursing procedures; and 3) organizing a related lecture for our department. The occlusion rates of AVG and AVF decreased from 18.6% to 7.4% and 5.2% to 0.9%, respectively. We significantly reduced AVG and AVF occlusion rates by using simple methods such as using a tourniquet ruler, designing big-print, illustrated patient instruction sheets on preventing low blood pressure, creating a simplified fistula puncture site series chart, creating a moisture control card, and scheduling follow-up visits for patients with abnormal blood flow at the OPD. This project provides a reference for other hemodialysis departments.

Comparison of Celox powder and conventional dressing on hemostasis of vascular access site in hemodialysis patients

Background: Common measures to stop bleeding can run the risk of clotting and thrombosis due to prolonged application of pressure. Topical homeostatic agents have an important role in decreasing time to hemostasis and consequently prevention of the complications. Aim: the aim of this study was to compare Celox powder and conventional bandage on time to hemostasis in the vascular access site in hemodialysis patients. Methods: This one-group, before-after, clinical-trial was conducted on 30 dialysis patients who had been selected by purposive sampling and underwent hemodialysis through arteriovenous fistula in Imam Reza and Montaserieh hospitals of Mashhad and Modarres hospital of Kashmar in 2013- 2014. The arteriovenous fistula puncture sites were treated with Celox powder dressing in three intermittent weeks. Time to hemostasis in each puncture site was calculated. Data were analyzed by repeated measures, Bonferroni correction, Friedman tests using SPSS version 11.5. Results: The mean age of patients was 54.2 ±14.3, and most of them (53.3 percent) were male. Time to hemostasis in the vascular access sites of patients was 9.8±1.9 minutes. There was a significant difference in the hemostasis time between using 1 gram Celox powder and conventional dressing,(p<0/001). There was also a significant difference in time to hemostasis between utilizing 0.5 gram Celox powder and conventional dressing (p<0/001). Conclusion: Using Celox powder reduces time to hemostasis in vascular access site in hemodialysis patient. Therefore, its use in patients with delayed vascular access site hemostasis is recommended.

Access of Dysfunctional Arteriovenous Fistulas via Outflow Vein Side Branches

The patterns of stenosis in dysfunctional arteriovenous (AV) fistulas (AVFs) are not as predictable as in synthetic AV grafts. Accessing of AV fistula venous side branches has the potential to provide bidirectional access to the fistula and may reduce the need for multiple fistula puncture sites via the use of the technique described here. Institutional review board approval was not required for the present report.

Application of improved wet sensors in the early warning of internal fistula needles prolapse

Objective To explore the warning effect of the improved wet sensor in the oozing and bleeding of internal fistula puncture site,so as to prevent the phenomenon of fistula needle slippage.Methods From January 2012 to June 2012,to select the 60 patients who accepted hemodialysis treatment by arteriovenous fistula needle,then to monitor the blood oozing and bleeding of fistula needle point with the improved wet sensors.Results The saline induction alarm sensitivity between the wet sensors with resistance value of 1.2 MΩ and 2.2 MΩ and the wet sensors with value of 2 000 Ω,significant differences were found (t =19.91,20.13 ; P ＜0.01).While no significant difference was found in saline induction alarm sensitivity between the wet sensors with resistance value of 1.2 MΩand of 2.2 MΩ (t =1.43,P ＞ 0.05).The sensitivity of wet sensors with resistance value of 1.2 MΩ and 2.2 MΩ was higher.when the oozing amount reached (1.21 ± 0.49) ml and (1.12 ± 0.50) ml,they were alerted.While there was no significant difference was found between them (t =0.73,P ＞ 0.05).Conclusions The wet sensor can effectively monitor and early warning the oozing and bleeding during the operation of internal fistula puncture point,and can effectively prevent the phenomenon of fistula needle slippage and avoid the harm of dialysis accident. Key words: Diffusion of innovation; Internal arteriovenous fistula; Wet sensor; Early warning; Puncture needle prolapse

Potential mechanisms of adverse outcomes in trials of anemia correction with erythropoietin in chronic kidney disease

Advanced chronic kidney disease (CKD, stages 3–5) is almost invariably associated with anemia that is primarily caused by depressed production of erythropoietin (EPO), oxidative stress and inflammation [1,2]. This can be compounded by iron deficiency that is caused by loss of blood from repetitive laboratory tests, residual blood remaining in the hemodialysis circuits, fistula puncture site bleeding and uremic platelet dysfunction. In addition, when present, hemolytic disorders, bone marrow suppression, nutritional deficiencies, drug toxicities and hereditary diseases exacerbate the CKD-associated anemia. The EPO-deficiency and iron-deficiency components of anemia are routinely corrected with the use of recombinant human EPO and iron preparations. However, presence of severe oxidative stress and inflammation hampers efficacy of EPO and iron in promoting erythropoiesis. In this context, severe persistent anemia despite high doses of EPO and iron is commonly due to oxidative stress and inflammation that may actually be intensified by intravenous iron and EPO administration [3–5]. Observational studies have revealed a strong association between severity of anemia and risk of morbidity and mortality from cardiovascular disease and other causes in CKD patients [6–10]. These findings have been widely interpreted as evidence for the causal role of anemia in the pathogenesis of adverse outcomes in this population. Contrary to expectations, randomized clinical trials of anemia correction revealed either no effect or increased morbidity and mortality in patients assigned to normal hemoglobin (Hb) targets [11–13]. In fact, meta-

Absorbable hemostatic agents

The pharmacology, clinical efficacy, adverse effects and toxicities, drug interactions, dosage and administration, and safety issues related to the use of absorbable hemostatic agents are reviewed. Absorbable hemostatic agents exert their pharmacologic effects at various points within the coagulation cascade. These agents are indicated for use during surgical procedures as adjunctive therapy when bleeding is not controlled by conventional methods. Early clinical data on absorbable hemostatic agents revealed a beneficial effect with regard to controlling capillary bleeding, achieving hemostasis during vascular surgery, and controlling bleeding from fistula-puncture sites. Few randomized controlled clinical trials have directly compared available agents, but case reports describing the efficacy of absorbable hemostatic agents in specific situations, especially unlabeled uses of thrombin, abound. Existing trials have compared the efficacy of established agents with newer agents, including fibrin sealants, with varying results. A variety of rarely occurring adverse effects have been reported with the administration of absorbable hemostatic agents; some of these rare effects, such as paralysis, are quite severe. No standardized dosing regimens are available for these agents, although surgeons may have a preference for a particular regimen based on their own clinical experience. No drug interactions involving absorbable hemostatic agents have been published; however, the use of these agents with other medications that affect hemostasis may disrupt clot formation. Absorbable hemostatic agents are useful as adjunctive therapy during surgical procedures when conventional methods do not control bleeding. Although rare adverse effects have occurred with these agents, their careful administration will prevent serious adverse outcomes.

Topical Thrombin and Control of Bleeding from the Fistula Puncture Sites in Dialyzed Patients

The length of bleeding from the puncture sites of internal arteriovenous channels was markedly reduced with the use of topical thrombin in 12 patients treated with hemodialysis. This procedure can, therefore, save patient and staff time, minimize recurrent blood loss with each dialysis, and prolong the life of vascular access by diminishing the length of potentially hazardous compression needed for proper hemostasis.

Reassessment of Fistula Puncture Site Blood Loss

Fistula puncture site blood loss during and after hemodialysis was measured in 12 patients with end-stage renal disease. It was found to be 0.74 +/- 0.32 ml per dialysis and 115.4 +/- 49.9 ml per year in patients with Cimino A-V fistulas. Puncture site blood leak in patients with heterologous grafts was 1.77 +/- 0.36 ml per dialysis and 276.1 +/- 56.1 ml per year. The values obtained in this study are 5 to 10 folds less than those found in the original reports. Recent advances in dialytic technology are probably responsible for the observed improvement. The results also suggest that Cimino A-V fistulas are superior to the heterologous graft.

HUMAN AEROMONAS INFECTIONS

Our patient, with cirrhosis and chronic renal failure, represents an example of the susceptibility of a compromised host to Aeromonas infections. This patient, however, differs from previously reported cases in at least two important aspects. First, it is possible that her portal of entry was a fresh A-V fistula puncture site rather than an intestinal site. The temporal relationship of exposure to flood water prior to the onset of sepsis lends support to this possibility. Epidemiologic investigation of the dialysis center failed to reveal Aeromonas isolates from cultures of the water supply, machinery, or other patients. Second, this case is unique in that our patient developed a destructive aortic valve endocarditis resulting in valvular perforations and acute aortic insufficiency. Furthermore, this infection was initiated on what appears to have been a previously normal valve. Based on a review of the literature and the virulence demonstrated by A. hydrophila in our patient, we conclude that organisms of the genus Aeromonas are capable of inducing serious human infection. Such infections are more likely to occur in compromised hosts. A. hydrophila has accounted for the majority of reported infections.

Clinical experience with therapeutic arteriovenous fistulae.

Brescia-Cimino arterio-venous fistulae have been used as blood access for intermittent hemodialysis in 67 patients between 1972-74. The mean age of 32 men and 35 women was 48. Thirty-five patients were dialyzed through an external arterio-venous shunt for as long as 7 years before they received a fistula. Of 92 operations, 63 (68.5%) were successful. Ten patients (14.9%) never received a functioning fistula. The mean function time of 63 fistulae was 8.3 months. Twenty-two functioning fistulae eventually failed. In 11 cases no precipitating factor could be found. In six patients, septicemia coincided with infection at the fistula puncture site. Cardiac decompensation because of augmented venous return to the heart was not observed. Advantages and disadvantages with the Brescia-Cimino fistula are discussed and compared with the Quinton-Scribner shunt.