Physical examination: How to examine the arm with arteriovenous fistula

How to choose the appropriate cannulation technique for vascular access in hemodialysis patients

The cannulation technique is important for the survival of the arteriovenous access. Choosing the appropriate technique is a complex decision. Such choice must be customized to patients, considering their characteristics, the type of arteriovenous access and the experience of the hemodialysis team. We describe seven items that can help nurses to identify the appropriate cannulation technique: type of arteriovenous access; drainage vein; hygienic self-care profile; experience of the nursing staff in the cannulation technique and nurse-to-patient ratio; hemodialysis treatment method; patient's condition; and patient's decision. Such items can help nurses in decision-making on the "ideal" cannulation technique for each patient.

Effects of Demographic and Clinical Character on Differences in Self-care Behaviour Levels with Arteriovenous Fistula by Haemodialysis Patients: An Ordinal Logistic Regression Approach

INTRODUCTION

Haemodialysis (HD) patients should be trained to develop self-care behaviors in order to prevent and preserve their arteriovenous fistula (AVF). The aim of this study was identifying the factors that affect the levels of self-care behavior with AVF by HD patients.

METHODS

A cross-sectional study was conducted involving 89 patients.

RESULTS

Self-care levels were negatively affected by patients' location (Azores) and positively affected by marital status, education, employment, AVF duration and absence of complications with the AVF. Concerning the management of signs and symptoms, self-care levels were negatively affected by patients' location. Regarding prevention of complications, self-care levels were negatively affected by age and marital status and positively affected by marital status, employment, CKD etiology, AVF duration and previous AVF.

CONCLUSION

Further studies are required in order to confirm whether the considered factors affect levels of self-care behaviors with AVF, or whether other factors are needed as well.

Ruptured arteriovenous fistula pseudoaneurysm treatment by balloon-assisted direct percutaneous thrombin injection

We present the case of a male patient on hemodialysis with a ruptured pseudoaneurysm in a brachiocephalic arteriovenous fistula (AVF) and with edema and pain in the right arm attended to in the emergency department. An ultrasonographic scan identified a ruptured pseudoaneurysm with hemorrhagic infiltration of the arm muscular tissues. We performed a percutaneous ultrasound-guided thrombin injection with an angioplasty balloon inflated in the lumen of the AVF achieving the pseudoaneurysm thrombosis. After 6 months of follow-up, the patient's arteriovenous access remains functional. Percutaneous ultrasound-guided thrombin injection assisted by an angioplasty balloon may be a good alternative to surgical intervention in the treatment of symptomatic growing pseudoaneurysms of the arteriovenous fistula with the benefit of preserving the vascular access.

Expert consensus on the establishment and maintenance of native arteriovenous fistula

Vascular access is the lifeline of hemodialysis patients. There are great differences in the establishment and use of vascular access in different countries and regions around the world. We believe that on the basis of good evaluation and planning, it is recommended that hemodialysis patients choose native arteriovenous fistula first. In view of the new progress of vascular access views domestic and international at home and abroad in recent years, we organized experts to recommend the establishment and maintenance of arteriovenous fistula (AVF) for the Chinese population, including preoperative evaluation and planning of the establishment of AVF, AVF surgery, perioperative drug intervention measures and postoperative maintenance, and put forward suggestions for future research directions. The recommendations in this consensus are general and clinicians need to make treatment decisions based on the actual situation.

Nursing care with surgical arteriovenous shunt in renal dialysis: a validation study

OBJECTIVES

to validate a care protocol for the monitoring and prevention of arteriovenous fistula complications.

METHODS

a validation methodological study with a quantitative approach, developed in a university hospital in the city of Rio de Janeiro.

RESULTS

scientific evidence was gathered from 20 researches. A care protocol was developed, composed of 15 items and divided into 3 sessions. The protocol was validated by a group of 11 experts, obtaining a content validity index of 0.95.

CONCLUSIONS

the protocol proposes nursing care capable of preventing and monitoring arteriovenous fistula complications, punctured with a traditional technique, taking into account the actions implemented from patients' entry into the machine until the end of therapy.

Self-care actions for the maintenance of the arteriovenous fistula: An integrative review

Objective

To identify self-care actions for the maintenance of arteriovenous fistula of renal patients.

Method

An integrative review study was conducted and literature were searched in Medline/PubMed, Scopus, CINAHL, LILACS, BDENF and SciELO Library databases using the descriptors chronic renal insufficiency, arteriovenous fistula, self-care, and knowledge. The inclusion criteria were that the documents be written in Portuguese, English, and Spanish, full text available, published in the last five years, and that they address the research question. Reflection articles, theses, dissertations, editorials of non-scientific journals, and research studies that did not follow the necessary methodological rigor were excluded. Data were analyzed with the IRAMUTEQ software.

Results

Fifteen articles were selected and comprised the final sample. Seven classes of self-care actions emerged from the text segments analysis and grouped into three categories: 1) Self-care actions that maintain the arteriovenous fistula; 2) Self-care actions for the prevention and the monitoring of complications with arteriovenous fistula; 3) Self-care actions directed at the perioperative period of arteriovenous fistula preparation.

Conclusion

The results allowed us to identify important care for the maintenance of arteriovenous fistula functionality. The self-care actions identified in this study can guide a nursing care policy for implementation with protocols that help identify problems related to self-care actions and, thus, subsidize the development of actions aimed at the renal patient. However, more studies with high levels of evidence that identify self-care actions with arteriovenous fistula and the factors involved in its implementation are needed.

Con: Vascular access surveillance in mature fistulas: is it worthwhile?

The risks and benefits of hemodialysis arteriovenous (AV) access surveillance have been debated since the introduction of AV access surveillance techniques. The debate is fuelled by the lack of robust, high-quality evidence with consistent and comparable patient-important outcomes. Additionally, there is a lack of clarity regarding the diagnostic cut points for AV access stenosis using the various surveillance techniques, questions about the appropriateness of the ‘knee-jerk’ response to intervention on a stenosis >50% regardless of the presence of clinical indicators and whether the intervention results in desired patient-important outcomes. The physiology of the AV access is complex considering the different hemodynamics within an AV fistula, which vary by time of dialysis, location, size of vessels and location of the stenosis. The current evidence suggests that the use of AV access surveillance in an AV fistula does detect more stenosis compared with clinical monitoring alone and leads to an increased number of procedures. It remains uncertain if that leads to improved patient-important outcomes such as prolonged AV fistula patency. Vascular access is an essential component of hemodialysis and further study is needed to clarify this long-standing debate. There needs to be better distinction between the strategies of vascular access surveillance, clinical monitoring with clinical indictors and preemptive intervention and their respective impacts on patient-important outcomes. Randomized controlled studies must be conducted with defined indications for intervention, reproducible methods of intervention and clinically important AV fistula and patient outcomes. The current guidelines need to be challenged and revised to permit these necessary studies to be done.

Physical examination of the hemodialysis arteriovenous fistula to detect early dysfunction

The maintenance of vascular access patency for end-stage renal disease patients on hemodialysis is necessary for survival. Many nephrologists, nurse practitioners, and nurses have limited experience with the physical examination of the arteriovenous fistula. In this review, we define key terms used in the assessment of an arteriovenous fistula. We discuss the arteriovenous fistula physical exam, including details of inspection, palpation, and auscultation. Using these concepts, we review the abnormal findings that can assist practitioners in determining the location of a stenosis. We review the existing literature that validates physical exam findings with gold standard tests such as ultrasound and angiography. Finally, we review data supporting the value of training physicians and nurses in arteriovenous fistula physical examination.

Structured physical assessment of arteriovenous fistulae in haemodialysis access surveillance: A missed opportunity?

Introduction:

Arteriovenous fistulae remain the gold standard of vascular access in haemodialysis. There is currently no consensus on standardised methods of monitoring arteriovenous fistulae. Assessment techniques and practice remain widely variable. The purpose of this study is to determine whether existing evidence supports physical assessment as an effective tool and a good predictor of arteriovenous fistulae dysfunction to allow for timely intervention and improve outcomes.

Methods:

A literature search was performed using CINAHL, PubMed, Medline and BNI databases and relevant search terms. Studies included were peer-reviewed, published after 2008, in English and related to arteriovenous fistulae only. Six key papers were identified and critically analysed for validity and relevance, in relation to outcomes, assessor experience, training duration and nurses’ ability to perform physical assessment.

Results:

Physical assessment has been shown to be effective in detecting arteriovenous fistulae dysfunction and comparable to technology-based surveillance. Physical assessment techniques generally adopt a ‘look, listen and feel’ approach to identify arteriovenous fistulae dysfunction that includes stenosis, thrombosis, ischaemia and infections. Physical assessment is a skill that can be taught with studies showing that skill-specific training is more effective than experience alone. Cost-effectiveness analysis is lacking.

Conclusion:

The analysis of evidence demonstrates that physical assessment of arteriovenous fistulae is an effective method of detecting arteriovenous fistulae dysfunction and is a skill that can be taught. A structured physical assessment and its implementation may be significant in routine care, but research into the most effective physical assessment techniques and its impact on clinical practice in haemodialysis is required.

Radio-cephalic fistula recovered with drainage to forearm basilic vein

Dysfunction problems with vascular access are a concern to patients and dialysis units. The vascular surgeon should analyse such dysfunction and perform a careful assessment of the vascular network in order to find new fistula layouts. We introduce and discuss the case of creation of a radio-cephalic fistula with outflow into the forearm basilic vein through rotation of the forearm basilic vein toward the cephalic vein in the forearm of an 88-year-old hemodialysis male patient. This technique enables extending fistula patency and improves cost efficiency.

The care and keeping of vascular access for home hemodialysis patients

Creating and maintaining a healthy vascular access is a critical factor in successful home hemodialysis (HD). This article aims to serve as a "how-to manual" regarding vascular access issues for both patients and health-care providers in a home HD program. This document outlines cannulation options for patients with arteriovenous access and describes troubleshooting techniques for potential complications; strategies are suggested to help patients overcome fear of cannulation and address problems associated with difficult cannulation. Technical aspects of central venous catheter care, as well as a guide to troubleshooting catheter complications, are covered in detail. Monitoring for access-related complications of stenosis, infection, and thrombosis is a key part of every home HD program. Key performance and quality indicators are important mechanisms to ensure patient safety in home HD and should be used during routine clinic visits.

Brachial-cephalic fistula recovered with drainage for the basilic vein: Case report

Vascular access is essential for the implementation of hemodialysis (HD). The arteriovenous fistula (AVF) can be constructed in various locations using various veins. However, the quality of the veins will influence the construction site, as well as the functioning of the AVF. Careful analysis of the vascular network allows options for the development of new fistulas presentations. We present and discuss the case of a woman aged 69 years in HD in which a brachial-cephalic fistula with drainage to basilic vein was created, through rotation of the cephalic vein on the forearm level. This kind of access serves to prolong the time spent dialyzing through native fistulae, with their reduced complications and greater cost-effectiveness.