RESUMEN
The use of vascular ultrasound, especially with the increasing prevalence of percutaneous arteriovenous fistulas, has taken a central role as a diagnostic and therapeutic imaging procedure in vascular access creation. The current review article stresses the importance of vascular ultrasound in arteriovenous fistula, from planning to creation to maintenance. It summarises and gives practical guidance regarding sonographic criteria for vascular access procedure planning, the application of vascular ultrasound intraoperatively and during follow-up. Ultrasound education and training modalities to meet high standards of patient care in hemodialysis are presented.
Asunto(s)
Fístula Arteriovenosa , Derivación Arteriovenosa Quirúrgica , Humanos , Derivación Arteriovenosa Quirúrgica/efectos adversos , Derivación Arteriovenosa Quirúrgica/educación , Diálisis Renal/métodos , Ultrasonografía , Ultrasonografía Doppler , Grado de Desobstrucción Vascular , Resultado del TratamientoRESUMEN
Ultrasound is an essential tool in the management of the nephrological patient allowing the diagnosis, monitoring and performance of kidney intervention. However, the usefulness of ultrasound in the hands of the nephrologist is not limited exclusively to the ultrasound study of the kidney. By ultrasound, the nephrologist can also optimize the management of arteriovenous fistula for hemodialysis, measure cardiovascular risk (mean intimate thickness), implant central catheters for ultrasound-guided HD, as well as the patient's volemia using basic cardiac ultrasound, ultrasound of the cava inferior vein and lungs. From the Working Group on Interventional Nephrology (GNDI) of the Spanish Society of Nephrology (SEN) we have prepared this consensus document that summarizes the main applications of ultrasound to Nephrology, including the necessary basic technical requirements, the framework normative and the level of training of nephrologists in this area. The objective of this work is to promote the inclusion of ultrasound, both diagnostic and interventional, in the usual clinical practice of the nephrologist and in the Nephrology Services portfolio with the final objective of offering diligent, efficient and comprehensive management to the nephrological patient.
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Consenso , Nefrología/educación , Ultrasonido/educación , Ultrasonografía Intervencional , Comités Consultivos , Derivación Arteriovenosa Quirúrgica/educación , Cateterismo/métodos , Competencia Clínica , Ecocardiografía , Humanos , Biopsia Guiada por Imagen , Nefrología/instrumentación , Diálisis Renal/métodos , España , Ultrasonido/instrumentaciónRESUMEN
Sonography is increasingly being used by nephrologists and the field of dialysis access is no exception. Advances in technology have allowed the addition of this universally available, portable, non-invasive tool to the nephrologist's armamentarium, which provides information on both morphology and physiology without the need for contrast or radiation. Ultrasound may be used across the spectrum of dialysis access, including central venous catheter placements, vascular mapping, regional anesthesia, creation, maintenance and assessment of hemodialysis access as well as assessment of the abdominal wall and peritoneal dialysis catheter placements. However, the lack of exposure in most training programs limits incorporation of routine use of ultrasounds in nephrology practice. As our specialty embarks on the ultrasound revolution, a two-pronged approach is essential to provide ample training opportunities while ensuring establishment of basic standards for training and competency.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/educación , Implantación de Prótesis Vascular/educación , Cateterismo Venoso Central , Educación de Postgrado en Medicina , Nefrólogos/educación , Diálisis Renal , Ultrasonografía Intervencional , Derivación Arteriovenosa Quirúrgica/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Cateterismo Venoso Central/efectos adversos , Cateterismo Venoso Central/instrumentación , Catéteres de Permanencia , Catéteres Venosos Centrales , Competencia Clínica , Curriculum , Humanos , Diálisis Peritoneal , Diálisis Renal/efectos adversos , Diálisis Renal/instrumentación , Ultrasonografía Intervencional/efectos adversosRESUMEN
End-stage kidney disease patients who are candidates for surgical arteriovenous fistula creation commonly experience obstacles to a functional surgical arteriovenous fistula, including protracted wait time for creation, poor maturation, and surgical arteriovenous fistula dysfunction that can result in significant patient morbidity. The recent approval of two endovascular devices designed to create a percutaneous arteriovenous fistula enables arteriovenous fistula creation to be placed in the hands of interventionalists, thereby increasing the number of arteriovenous fistula providers, reducing wait times, and allowing the patient to avoid surgery. Moreover, current studies demonstrate that patients with percutaneous arteriovenous fistula experience improved time to arteriovenous fistula maturation. Yet, in order to realize the potential advantages of percutaneous arteriovenous fistula creation within our hemodialysis patient population, it is critical to select appropriate patients, ensure adequate patient and dialysis unit education, and provide sufficient instruction in percutaneous arteriovenous fistula cannulation and monitoring. In this White Paper by the American Society of Diagnostic and Interventional Nephrology, experts in interventional nephrology, surgery, and interventional radiology convened and provide recommendations on the aforementioned elements that are fundamental to a functional percutaneous arteriovenous fistula.
Asunto(s)
Derivación Arteriovenosa Quirúrgica , Cateterismo , Toma de Decisiones Clínicas , Procedimientos Endovasculares , Fallo Renal Crónico/terapia , Diálisis Renal , Derivación Arteriovenosa Quirúrgica/efectos adversos , Derivación Arteriovenosa Quirúrgica/educación , Cateterismo/efectos adversos , Competencia Clínica , Consenso , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/educación , Conocimientos, Actitudes y Práctica en Salud , Personal de Salud/educación , Humanos , Fallo Renal Crónico/diagnóstico , Grupo de Atención al Paciente , Educación del Paciente como Asunto , Selección de Paciente , Factores de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVE: The operative caseload of a surgeon has a positive influence on post-operative outcomes. For surgical trainees to progress effectively, maximising operating room exposure is essential, vascular surgery being no exception. Our aim was to ascertain the impact of supervised trainee led vs. expert surgeon led procedures on post-operative outcomes, across three commonly performed vascular operations. METHODS: A literature search was undertaken using the MEDLINE, Web of Science, and Cochrane databases up to 1 January 2018. Studies reporting outcomes following major lower limb amputation, fistula formation, or carotid endarterectomy (CEA) that involved a direct comparison between supervised trainee and experts were included, with odds ratios (ORs) calculated. Primary outcomes varied depending on the specific procedure: amputations-rate of amputation revision within 30 days; fistula formation-primary patency; CEA-stroke rate at 30 days. Meta-analysis with the Mantel-Haenszel method was performed for each outcome. RESULTS: Sixteen studies were included in the final review. Overall, trainees accounted for a third of all procedures analysed (n = 2 421/7 017; 34.5%). Only one study was identified that described rates of amputation revision, precluding any further analysis. Four studies on fistula formation were included, showing no significant difference in outcomes between trainees and experts in primary patency (OR 1.68, 95% confidence interval [CI] 0.42-6.75). Nine studies were identified reporting post-CEA stroke rates, also demonstrating no difference between trainees and experts (OR 0.89, 95% CI 0.59-1.32). CONCLUSION: In select cases, with appropriate training and suitable experience, supervised trainees can perform surgical procedures without any detriment to patient care. To ensure high standards for patients of the future, supported training programmes are essential for today's surgical trainees.
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Competencia Clínica , Educación de Postgrado en Medicina , Cirujanos/educación , Procedimientos Quirúrgicos Vasculares/educación , Amputación Quirúrgica/educación , Derivación Arteriovenosa Quirúrgica/educación , Endarterectomía Carotidea/educación , Humanos , Curva de Aprendizaje , Seguridad del Paciente , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Carga de TrabajoRESUMEN
INTRODUCTION: Access surgery is delivered by vascular/transplant surgeons with a division that is defined by historic practice. This has resulted in an inconsistent training pattern. We aimed to design a focused, modular training program (The Brighton Vascular Access Fellowship) providing trainees with a reproducible level of exposure and competence. METHODS: The programme was 16 days over 8 weeks on a one-to-one basis with candidates expected to be performing procedures as first surgeon with ongoing, formative assessment. The outpatient setting took the format of a one-stop clinic to involve planning and the follow-up. Assessment was through caseload exposure and conventional statistical analyses to obtain median values (as proxy measures of training exposure consistency). Assessment of confidence and capability was through an electronically distributed qualitative survey tool. RESULTS: A total of 14 candidates completed the programme by June 2017. Operative exposure was obtained for 11 (79%) with a total of 471 cases of which 286 were conducted as first surgeon. There was a median of 32 cases by each candidate with 25 of the cases performed as first surgeon. Qualitative assessment revealed that 13 of 14 (93%) were either practicing independently or no longer required the trainer to scrub in for the operation. A total of 13 of 14 (93%) strongly agreed that they felt comfortable with offering a basic access service. CONCLUSIONS: Focused modular training might be one of the answers to the current era of restricted and sometimes inconsistent training in some aspects of surgery. This model is reproducible and may be applicable in other aspects of training.
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Derivación Arteriovenosa Quirúrgica/educación , Implantación de Prótesis Vascular/educación , Educación de Postgrado en Medicina/métodos , Becas , Cirujanos/educación , Derivación Arteriovenosa Quirúrgica/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Competencia Clínica , Curriculum , Estudios de Factibilidad , Humanos , Curva de Aprendizaje , Evaluación de Programas y Proyectos de Salud , Análisis y Desempeño de Tareas , Carga de TrabajoAsunto(s)
Derivación Arteriovenosa Quirúrgica , Educación Médica Continua/métodos , Educación de Postgrado en Medicina/métodos , Aumento de la Imagen/instrumentación , Microcirugia/instrumentación , Vena Safena/cirugía , Derivación Arteriovenosa Quirúrgica/educación , Derivación Arteriovenosa Quirúrgica/instrumentación , Competencia Clínica , Diseño de Equipo , Humanos , Internado y Residencia , Curva de Aprendizaje , Microcirugia/educación , Técnicas de SuturaRESUMEN
End-stage renal disease is a worldwide problem that requires highly skilled nursing care. Hemodialysis (HD) is a corner-stone procedure in the management of most patients who require renal replacement therapy. Adequate vascular access is essential for the successful use of HD. Appropriate knowledge in taking care of vascular access is essential for minimizing complications and accurately recognizing vascular access-related problems. This study was to evaluate the effect of an educational program for vascular access care on nurses' knowledge at nine dialysis centers in Khartoum State. This was a Quasi experimental study (pre-and post-test for the same group). Sixty-one nurses working in these HD centers were chosen by simple random sampling method. A structured face-to-face interview questionnaire based on the Kidney Dialysis Outcome Quality Initiative (K/DOQI) clinical practice guidelines for vascular access care was used. Instrument validity was determined through content validity by a panel of experts. Reliability of the instrument was tested by a pilot study to test the knowledge scores for 15 nurses. The Pearson correlation coefficient obtained was (r = 0.82). Data collection was taken before and after the educational intervention. A follow-up test was performed three month later, using the same data collection tools. Twenty-two individual variables assessing the knowledge levels in aspects related to the six K/DOQI guidelines showed improvement in all scores of the nurses' knowledge after the educational intervention; and the differences from the preeducational scores were statistically significant (P < 0.001). The study showed that a structured educational program based on the K/DOQI clinical practice guidelines had a significant impact on the dialysis nurses knowledge in caring for vascular access in HD patients. The knowledge level attained was maintained for at least three months after the educational intervention.
Asunto(s)
Instituciones de Atención Ambulatoria , Derivación Arteriovenosa Quirúrgica/enfermería , Implantación de Prótesis Vascular/enfermería , Cateterismo Venoso Central/enfermería , Educación Continua en Enfermería/métodos , Capacitación en Servicio/métodos , Fallo Renal Crónico/enfermería , Personal de Enfermería/educación , Diálisis Renal/enfermería , Adulto , Derivación Arteriovenosa Quirúrgica/educación , Actitud del Personal de Salud , Implantación de Prótesis Vascular/educación , Competencia Clínica , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Fallo Renal Crónico/diagnóstico , Masculino , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , SudánRESUMEN
INTRODUCTION: There is still an ongoing discussion about the influence of vascular surgeon experience on the immediate and long-term outcome of newly created arteriovenous fistula (AVF) for patients on hemodialysis (HD). The aim of this study was to compare failure and patency rates of AVF between experienced consultants and resident trainees with special focus on location of the anastomosis on the forearm or upper arm. METHODS: Between November 2012 and September 2016, 159 patients (83 on HD and 76 preemptive) received an AVF (90 radiocephalic [RCAVF] on the forearm; 69 brachiocephalic [BCAVF] in the elbow) by two experienced vascular surgeons (group A; n = 74) or five residents in training with one-to-four years of experience (group B; n = 85). We compared the two groups for demographic and treatment data, immediate failures (IF), bleeding complications and patency rates. RESULTS: There were no significant differences in demographic data between the two groups. Vessel diameters were significantly lower for forearm compared to upper arm arteries (p = 0.026) and veins (p = 0.05). There was a significantly increased risk for IF in group B for RCAVF (p = 0.003), but not for BCAVF (p = 1.000). Furthermore, the cumulative primary patency was reduced in group B for RCAVF (p<0.001), but not for BCAVF (p = 0.899). CONCLUSION: Surgeon experience seems to have more influence on the immediate and long-term outcome of newly created forearm AVF compared to those located on the upper arm.
Asunto(s)
Brazo/irrigación sanguínea , Derivación Arteriovenosa Quirúrgica/métodos , Competencia Clínica , Antebrazo/irrigación sanguínea , Fallo Renal Crónico/terapia , Curva de Aprendizaje , Diálisis Renal , Cirujanos , Anciano , Anciano de 80 o más Años , Derivación Arteriovenosa Quirúrgica/efectos adversos , Derivación Arteriovenosa Quirúrgica/educación , Educación de Postgrado en Medicina , Femenino , Alemania , Humanos , Internado y Residencia , Fallo Renal Crónico/diagnóstico , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Cirujanos/educación , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE The authors previously demonstrated the use of a validated Objective Structured Assessment of Technical Skills (OSATS) tool for evaluating residents' operative skills in pediatric neurosurgery. However, no benchmarks have been established for specific pediatric procedures despite an increased need for meaningful assessments that can either allow for early intervention for underperforming trainees or allow for proficient residents to progress to conducting operations independently with more passive supervision. This validated methodology and tool for assessment of operative skills for common pediatric neurosurgical procedures-external ventricular drain (EVD) placement and shunt surgery- was applied to establish its procedure-based feasibility and reliability, and to document the effect of repetition on achieving surgical skill proficiency in pediatric EVD placement and shunt surgery. METHODS A procedure-based technical skills assessment for EVD placements and shunt surgeries in pediatric neurosurgery was established through the use of task analysis. The authors enrolled all residents from 3 training programs (Baylor College of Medicine, Houston Methodist Hospital, and University of Texas-Medical Branch) who rotated through pediatric neurosurgery at Texas Children's Hospital over a 26-month period. For each EVD placement or shunt procedure performed with a resident, the faculty and resident (for self-assessment) completed an evaluation form (OSATS) based on a 5-point Likert scale with 7 categories. Data forms were then grouped according to faculty versus resident (self) assessment, length of pediatric neurosurgery rotation, postgraduate year level, and date of evaluation ("beginning of rotation," within 1 month of start date; "end of rotation," within 1 month of completion date; or "middle of rotation"). Descriptive statistical analyses were performed with the commercially available SPSS statistical software package. A p value < 0.05 was considered statistically significant. RESULTS Five attending evaluators (including 2 fellows who acted as attending surgeons) completed 260 evaluations. Twenty house staff completed 269 evaluations for self-assessment. Evaluations were completed in 562 EVD and shunt procedures before the surgeons left the operating room. There were statistically significant differences (p < 0.05) between overall attending (mean 4.3) and junior resident (self; mean 3.6) assessments, and between overall attending (mean 4.8) and senior resident (self; mean 4.6) assessment scores on general performance and technical skills. The learning curves produced for the residents demonstrate a stereotypical U- or V-shaped curve for acquiring skills, with a significant improvement in overall scores at the end of the rotation compared with the beginning. The improvement for junior residents (Δ score = 0.5; p = 0.002) was larger than for senior residents (Δ score = 0.2; p = 0.018). CONCLUSIONS The OSATS is an effective assessment tool as part of a comprehensive evaluation of neurosurgery residents' performance for specific pediatric procedures. The authors observed a U-shaped learning curve, contradicting the idea that developing one's surgical technique and learning a procedure represents a monotonic, cumulative process of repetitions and improvement.
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Competencia Clínica , Evaluación Educacional/métodos , Estudios de Evaluación como Asunto , Procedimientos Neuroquirúrgicos , Pediatría/educación , Derivación Arteriovenosa Quirúrgica/educación , Drenaje/métodos , Femenino , Humanos , Internado y Residencia/normas , Curva de Aprendizaje , Estudios Longitudinales , Masculino , Procedimientos Neuroquirúrgicos/educación , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/normas , Pediatría/métodos , Reproducibilidad de los Resultados , Estudios RetrospectivosRESUMEN
BACKGROUND/AIM: Vascular access (VA) cannulation is an essential skill for dialysis nurses: failure to correctly repeat this operation daily may result in serious complications for the patients. This study investigates if different aspects of arteriovenous fistula and graft cannulation have an effect on the development of acute access complications, which may affect the VA survival. METHODS: In April 2009 a cross-sectional survey was conducted in 171 dialysis units located in Europe, the Middle East and Africa to collect details on VA cannulation practices. Information on cannulation retrieved from the survey comprised fistula type and location, cannulation technique, needle size, use of disinfectants and of local anaesthetics, application of arm compression at the time of cannulation, needle and bevel direction, needle rotation, and needle fixation. Five categories of complications were investigated: multiple-cannulation, infiltration, haematoma, haemorrhage and unknown. RESULTS: There were 10,807 cannulation procedures evaluated in the same number of patients. Of these, 367 showed some kind of complication, the most frequent (33.8%) being the need for multiple-cannulation. The following were associated with a significantly higher odds ratio for occurrence of an acute complication: prescription of back-eye needles, use of rope-ladder cannulation technique, insertion of venous needle as first needle, and rotation of the arterial needle. Use of 16-17-gauge needles was also significantly associated with complications, but this possibly reflects poor quality of the VA. CONCLUSIONS: The risk of an acute VA complication could be reduced with appropriate training of nurses, physicians and patients. This could potentially prolong the VA life.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/enfermería , Cateterismo/enfermería , Rol de la Enfermera , Personal de Enfermería , Diálisis Renal/enfermería , Derivación Arteriovenosa Quirúrgica/efectos adversos , Derivación Arteriovenosa Quirúrgica/educación , Cateterismo/efectos adversos , Competencia Clínica , Estudios Transversales , Educación Continua en Enfermería , Encuestas de Atención de la Salud , Humanos , Capacitación en Servicio , Oportunidad Relativa , Pautas de la Práctica en Enfermería , Factores de Riesgo , Resultado del TratamientoRESUMEN
Access to the circulation is an "Achilles' heel" of chronic hemodialysis. According to the current guidelines, autologous arteriovenous fistula is the best choice available. However, the impossibility of immediate use and the high rate of non-matured fistulas place fistula far from an ideal hemodialysis vascular access. The first attempt at constructing an angioaccess should result in functional access as much as possible. After failed attempts, patients and nephrologists lose their patience and confidence, which results in high percentage of central venous catheter use. Predictive models could help, but clinical judgment still remains crucial. Early referral to the nephrologist and vascular access surgeon, careful preoperative examinations, preparation of patients and duplex sonography mapping of the vessels are very important in the preoperative stage. In the operative stage, it is crucial to understand that angioaccess procedures should not be considered as minor procedures and these operations must be performed by surgeons with demonstrable interest and experience. In the postoperative stage, appropriate surveillance of the maturation process is also important, as well as good cannulation skills of the dialysis staff. The purpose of this review article is to stress the importance of success prediction in order to avoid unsuccessful attempts in angioaccess surgery.
Asunto(s)
Derivación Arteriovenosa Quirúrgica , Diálisis Renal , Derivación Arteriovenosa Quirúrgica/educación , Competencia Clínica , Predicción , Humanos , Cuidados Posoperatorios , Cuidados Preoperatorios , Insuficiencia del TratamientoRESUMEN
PURPOSE: Medical education and training in dialysis access skills remains complex and inadequate as learners come from diverse backgrounds and from various specialties so that appropriate training is limited. As a result, a system of progressive education including live lectures, and hands on training has emerged, but there is controversy as to what constitutes the best educational model. METHODS: Presently there is no recognized or structured training in vascular access during residency or fellowships. Here we present a model of dialysis access training for beginner to advanced surgeons. RESULTS: A structured hands-on and didactic surgery training certification course consisting of a one week curriculum with 49 hours of ACCME credit hours has been in effect for one year. The learning impact and the performance outcome are high but with limited attendance capacity. Pre- and post- training test results attest to training effectiveness. To increase access, an off-site training curriculum has been initiated, entailing 1-2 days (8-15 credit hours) consisting of didactic lectures and surgical training. This teaching module has moderate learning impact for 50-100 attendees.Finally, a tiered, web-based training curriculum (10 ACCME credit hours) can accommodate an unlimited number of learners, but has a lower skills learning impact. CONCLUSIONS: The future dialysis access training must also accommodate learners with diverse individual backgrounds, and different levels of professional (skill) development. To be effective and accessible, a variety of educational system, for example on site or web based is needed. Collaborative initiatives for global dialysis access training are currently underway.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/educación , Curriculum , Educación de Postgrado en Medicina/métodos , Becas , Internado y Residencia , Enfermedades Renales/terapia , Modelos Educacionales , Diálisis Renal , Certificación , Competencia Clínica , Humanos , Curva de Aprendizaje , Teoría de Sistemas , Factores de TiempoRESUMEN
INTRODUCTION: The Japanese Society for Dialysis Access (JSDA) has held the practical skills trainings for the doctors working for the vascular access (VA) access since 2014 in order to improve both quality and quantity of the VA construction. Terumo Medical Pranex (Kanagawa, Japan) is the institution of the general medical training established for the creation and the spread of medical technique, and it also has the hybrid simulator of VA. METHODS AND RESULTS: In the training institute in 2014, not only the practical skills but also the training on the simulator from the basic lecture of VA construction were conducted. The dummy of a radical artery and a cephalic vein is faked in the forearm on the simulator. Two carotid arteries of a pig are made as the position of a pair of artery and vein. The pig's skin taken from the neck to the chest is covered on the proceed part, then the dummy forearm was completed. We can make recognize the beats in the artery. We also can make a fake avf in the dummy forearm instead. The instructor is directly able to give the trainees the lectures while watching the scenes. jsda will continue to make such efforts from now. CONCLUSIONS: We are concerned that the more the VA access would be demanded, the more the VA construction would be needed. So, the matter of the urgency is the training of the doctors working for VA construction.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/educación , Implantación de Prótesis Vascular/educación , Venas Braquiocefálicas/cirugía , Competencia Clínica , Educación Médica Continua/métodos , Arteria Radial/cirugía , Diálisis Renal , Enseñanza/métodos , Animales , Derivación Arteriovenosa Quirúrgica/efectos adversos , Derivación Arteriovenosa Quirúrgica/normas , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/normas , Arterias Carótidas/cirugía , Competencia Clínica/normas , Educación Médica Continua/normas , Humanos , Japón , Modelos Anatómicos , Modelos Animales , Modelos Cardiovasculares , Diálisis Renal/normas , PorcinosRESUMEN
PURPOSE: Arteriovenous fistula (AVF) surgery affords an excellent opportunity for junior surgeons to learn key vascular techniques. However, implementation of the European Working Time Directive has reduced trainee surgeon's working hours, leading to concerns regarding a possible effect on patient outcomes. Given high early postoperative failure rates and limited AVF sites, it has been proposed that AVF surgery should be performed by Consultants and senior trainees only. This prospective observational study aimed to establish how seniority impacts upon AVF surgery outcomes. METHODS: All patients referred for AVF formation were considered for inclusion. Demographic data, comorbidities, medications and previous access history were recorded. Surgery was performed by a Consultant Vascular Surgeon or a junior surgeon. Clinical review was undertaken 30 days postoperatively to assess patency and record any complications. RESULTS: Seventy-seven patients underwent AVF formation. About 63.6% procedures were carried out by a junior surgeon. The groups were well matched for demographics, comorbidities and medications. There was no difference in anatomical site of formation between groups operated on by consultant versus juniors (p = 0.373). More general anaesthetic procedures were undertaken by Consultant surgeons, for example basilic vein transposition when compared with juniors (p = 0.039). There was no significant difference in terms of early AVF failure (p = 0.710), complication rates (p = 0.139) or requirement for re-intervention (p = 0.256) between the groups. Patency rates were also equivocal between the groups. CONCLUSIONS: The seniority of the operating surgeon does not appear to impact on outcomes following AVF formation. A greater proportion of general anaesthetic cases were undertaken by a Consultant, which may introduce bias. Junior surgeons with appropriate training and modest experience can perform access surgery without detriment to patients patient detriment.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/educación , Competencia Clínica , Educación de Postgrado en Medicina , Diálisis Renal , Cirujanos/educación , Derivación Arteriovenosa Quirúrgica/efectos adversos , Humanos , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
BACKGROUND: An arteriovenous fistula (AVF), performed for hemodialysis access, provides one of the few remaining opportunities for general surgery residents to perform an open vascular anastomosis (VA). Limited data exist regarding the learning curve of residents performing this procedure. The objective of this study was to determine how residents improve in performance of VA by implementing real-time tracking of anastomosis time as well as technical errors. STUDY DESIGN: From April 2012 to January 2014, we conducted a prospective intraoperative assessment of 9 postgraduate year 3 general surgery residents during the performance of AVFs using a checklist of common errors in VA. Time for AVF anastomosis completion and number and types of technical errors during anastomosis were recorded. Primary end points were the change in anastomosis time and change in technical errors over time. RESULTS: A total of 86 AVFs were performed and assessed intraoperatively. Each resident performed a median of 10 AVFs (interquartile range [IQR]: 7-11). The mean anastomosis time was 18.1 minutes. The mean number of technical errors was 13.8 per case. Overall, for every additional AVF performed, mean anastomosis time decreased by 0.63 minutes (95% CI: 0.45-0.81, p < 0.0001) and the mean number of technical errors decreased by 1.0 (95% CI: 0.7-1.3, p < 0.0001). The greatest improvement in overall errors (mean difference = 7.9, p = 0.03) and time (mean difference = 4.7min, p = 0.03) occurred after the performance of 3 AVFs. However, when analyzed by individual resident, the R(2) value for anastomotic time by number of AVFs performed ranged from 0.01 to 0.69. Similarly, for technical errors, the R(2) value by number of AVFs performed ranged from 0.04 to 0.62. CONCLUSIONS: In novice surgical residents performing AVFs, improvement in VA skill can readily be tracked via anastomosis time and technical errors. Collectively, there is a strong association between number of cases performed and reduction in time and errors. However, individually, the number of cases completed did not correlate well with time and errors. These findings suggest that for VA skills, determining progression from novice to competence cannot rely on case volume but rather needs to be individualized.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/educación , Educación de Postgrado en Medicina/métodos , Cirugía General/educación , Curva de Aprendizaje , Competencia Clínica , Femenino , Humanos , Internado y Residencia , Masculino , Diálisis Renal , Estudios RetrospectivosRESUMEN
Exponential growth and increasing longevity of end-stage renal disease (ESRD) has resulted in significant ongoing changes in vascular access (VA) planning and management in the United States. There is a positive trend showing an increase in arteriovenous fistula (AVF) prevalence both in incident and prevalent patients and a decrease in tunneled dialysis catheters (TDCs) in prevalent patients. Current surgical training seems to provide adequate exposure to VA and an ample opportunity to develop skills required for safe surgical placement of VA. The prevalent differences in practice patterns suggest a need for standardization of VA care. There is a need for a structured curriculum in VA, which is a critical component in making sound decisions in access planning and management.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/tendencias , Cateterismo Venoso Central/tendencias , Atención a la Salud/tendencias , Fallo Renal Crónico/terapia , Pautas de la Práctica en Medicina/tendencias , Diálisis Renal/tendencias , Derivación Arteriovenosa Quirúrgica/educación , Derivación Arteriovenosa Quirúrgica/normas , Cateterismo Venoso Central/normas , Competencia Clínica , Atención a la Salud/normas , Educación de Postgrado en Medicina/tendencias , Humanos , Incidencia , Fallo Renal Crónico/diagnóstico , Fallo Renal Crónico/epidemiología , Pautas de la Práctica en Medicina/normas , Prevalencia , Mejoramiento de la Calidad/tendencias , Indicadores de Calidad de la Atención de Salud/tendencias , Diálisis Renal/normas , Estados Unidos/epidemiologíaRESUMEN
Rapidly growing technical developments and working time constraints call for changes in trainee formation. In reality, trainees spend fewer hours in the hospital and face more difficulties in acquiring the required qualifications in order to work independently as a specialist. Simulation-based training is a potential solution. It offers the possibility to learn basic technical skills, repeatedly perform key steps in procedures and simulate challenging scenarios in team training. Patients are not at risk and learning curves can be shortened. Advanced learners are able to train rare complications. Senior faculty member's presence is key to assess and debrief effective simulation training. In the field of vascular access surgery, simulation models are available for open as well as endovascular procedures. In this narrative review, we describe the theory of simulation, present simulation models in vascular (access) surgery, discuss the possible benefits for patient safety and the difficulties of implementing simulation in training.