Utilização do exame físico na avaliação da funcionalidade das fístulas arteriovenosas para hemodiálise / Use of physical examination to assess the functionality of arteriovenous fistulas for hemodialysis / Utilización del examen físico en la evaluación de la funcionalidad de las fístulas arteriendas para hemodiálisis

Objetivo: Avaliar através do exame físico (EF) alterações presentes na fístula arteriovenosa (FAV) durante o período de maturação e propor um protocolo de avaliação pós-operatória que inclua esse método. Métodos: Estudo longitudinal com abordagem quantitativa. Resultados: Foram incluídos na amostra 17 pacientes, dos quais dois realizaram mais de um procedimento de construção da FAV em virtude do insucesso dos procedimentos iniciais, sendo totalizadas 20 FAV avaliadas. Houve um predomínio do sexo masculino e a idade média foi de 51,8 anos. Conclusão: O EF mostrou-se útil na avaliação da funcionalidade da FAV e sugere-se que o protocolo elaborado possa ser validado e utilizado na prática do serviço, aumentando a qualidade da assistência de enfermagem prestada ao portador de FAV

Objective: evaluate by physical examination changes present in the arteriovenous fistula during the maturation period and to propose a protocol of postoperative evaluation. Materials and methods: patients submitted to the construction of the access were interviewed and two physical exams were performed: the first between 24 and 48 hours after surgery and the second on the 15th postoperative day. Results: a total of 20 arteriovenous fistulas were evaluated, with predominance of males and mean age of 51.8 years. Hypertension was the most prevalent comorbidity (94.1%), followed by diabetes (47%). The Body Mass Index was in the range of normality in the majority (64.7%) and 58.8% were already in dialysis, 90% with a temporary catheter. Only six (30%) accesses had an early failure. Conclusion: the physical examination was useful in assessing the functionality of access and it is suggested that the protocol elaborated can be validated and used in the practice

Objetivo: evaluar por medio del examen físico alteraciones presentes en la fístula arteriovenosa durante el período de maduración y proponer un protocolo de evaluación. Materiales y métodos: fueron entrevistados pacientes sometidos a la construcción del acceso y realizados dos exámenes: el primero entre 24 a 48 horas y el segundo en el 15º día del postoperatorio. Resultados: se evaluaron 20 fístulas, observándose un predominio del sexo masculino y edad media de 51,8 años. La hipertensión fue la comorbilidad más prevalente (94,1%), seguida de la diabetes (47%). El índice de masa corporal se mostró en el rango de la normalidad en la mayoría (64,7%) y 58,8% se encontraba en tratamiento dialítico, 90% con cateter temporario. En sólo seis accesos (30%) se constató fracaso. Conclusión: el examen físico se mostró útil en la evaluación y se sugiere que el protocolo elaborado pueda ser validado y utilizado en la práctica del servicio

A prospective cohort study of predictors of upper extremity arteriovenous fistula maturation.

BACKGROUND: A substantial proportion of arteriovenous fistulas fail to function adequately for hemodialysis. Existing studies on arteriovenous fistula failure prediction assess patency rather than the more clinically relevant outcome of arteriovenous fistula function. We hypothesized that preoperative demographic and ultrasound characteristics, and postoperative assessment by an experienced vascular access nurse would predict which arteriovenous fistulas will not function adequately for hemodialysis. METHODS: Prospective cohort study of chronic kidney disease patients at a tertiary care center in Vancouver, Canada, with arteriovenous fistula creation between 2009 and 2013. Pre and postoperative clinical assessment and ultrasound blood vessel mapping were performed by an experienced vascular access nurse. The primary outcome was failure to achieve a fistula used successfully for hemodialysis (FUSH). RESULTS: Outcomes were assessed in 200 patients; 123 (61.5%) arteriovenous fistulas were radiocephalic. Overall, 26.5% of arteriovenous fistulas had FUSH failure (34.1% of lower arm vs 14.3% of upper arm, p = 0.002). Univariate predictors of FUSH failure included older age (p = 0.03), female sex (p = 0.05), smaller arterial diameter (p ⩽ 0.001), lower artery volume flow (p = 0.04), and smaller vein diameter (p = 0.01). In multivariable analysis, artery diameter (odds ratio: 0.44, 95% confidence interval: 0.28-0.68) most significantly predicted FUSH failure. Vascular access nurse assessment 6 weeks postoperatively correctly predicted outcome in 83.8% of FUSH and 65.0% of FUSH failure. CONCLUSION: Smaller artery diameter most strongly predicted FUSH failure. Early postoperative nursing assessment was more useful to predict FUSH than FUSH failure, and as such was insufficient in determining which arteriovenous fistulas should be abandoned as many predicted to fail could be salvaged with further intervention.

Fístula arteriovenosa para hemodiálise: da pré-construção à primeira punção: o papel do enfermeiro especialista no follow up / Arteriovenous fistula for hemodialysis: from pre-construction to the first puncture: the role of specialist nurses in follow-up

Este documento permitirá o leitor acompanhar o mestrando no seu percurso académico relativo aos ensinos clínicos, nas diferentes unidades de saúde da especialidade Nefrológica. Serão descritas as atividades relacionadas à aquisição e desenvolvimento de competências comuns e específicas do enfermeiro especialista contempladas pela Ordem dos Enfermeiros, (2010; 2011) e as que são definidas pela European Dialysis & Transplant Nurses Association/European Renal Care Association ­ EDTNA/ERCA (Chamney, 2007). Será redigida uma reflexão sustentada pelos níveis de aquisição de competências do modelo de Dreyfus, aplicado por Benner (2001) à prática de enfermagem. Evidenciando, conforme os descritores de Dublin, uma prática reflexiva, com capacidade de articulação do conhecimento nos vários contextos multidisciplinares e suportada em elementos de investigação. De acordo com o projeto de estágio, elaborado na fase preparatória, este relatório cumprirá o seu objetivo relativamente ao tema em estudo "Da pré-construção à primeira punção: O papel do Enfermeiro Especialista no follow up da fistula arteriovenosa para Hemodiálise", através de uma revisão scoping. Mapeando evidência científica que sustente a importância do follow up, numa consulta de enfermagem de acessos vasculares. Neste sentido, dos artigos selecionados organizamse duas grandes áreas relativas ao papel do enfermeiro, as competências teórico-práticas, e o apoio-educação ao utente durante os diferentes momentos do acesso arteriovenoso. O enfermeiro especialista deve ser capaz de dinamizar na sua unidade de saúde, aspetos formativos que viabilizem a aquisição de competências teórico-práticas, e permitir que estas se desenvolvam ao longo da sua experiência clínica, numa perspetiva contínua de partilha de conhecimentos entre a equipa de enfermagem e o utente. Estes conhecimentos teóricos e competências práticas permitem cuidados de enfermagem direcionados para o utente com fistula arteriovenosa, garantindo assim cuidados qualificados. No respeitante ao apoio-educação ao utente, duas áreas de atenção "vigilância do acesso" e "capacitação do autocuidado", foram identificadas (Sousa, Apóstolo, Figueiredo, Martins & Dias, 2013). A primeira área engloba os cuidados de enfermagem no período pré e pós construção da fístula arteriovenosa. A área "capacitação do autocuidado" engloba 4 dimensões: cuidados antecipatórios na preparação da fístula arteriovenosa; cuidados nas 48 horas após a construção da fístula arteriovenosa; cuidados específicos com o processo de maturação da fístula arteriovenosa e cuidados específicos em programa regular de hemodiálise (Sousa et al 2013). As quatro dimensões referidas, e a Teoria do Défice de Autocuidado de Enfermagem, de Orem (2001), formam deste modo, um suporte orientador para o enfermeiro relativo à conceção e aplicação de um plano de intervenções para a consulta de enfermagem de acessos vasculares, durante os diferentes momentos da fístula arteriovenosa. Através das suas três teorias, a Teoria do Autocuidado, a Teoria do Défice de Autocuidado e a Teoria dos Sistemas de Enfermagem, a sua aplicabilidade neste contexto é manifesta, na medida em que permite diagnosticar o défice de conhecimento relativamente à fistula arteriovenosa, capacitando o utente para dar resposta ao requisito de autocuidado do acesso, através do sistema apoio-educação. Assim, o envolvimento efetivo do utente, desde a pré-construção até à primeira punção do acesso, comprometerá o mesmo à execução do autocuidado, diminuindo a ansiedade (Mollaoglu, Tuncay, Fertelli & Yürügen, 2012) e beneficiando de um processo de coping positivo (Romyn, Rush & Hole, 2015), aquando da primeira punção. É então, importante manter o suporte de apoio-educação ao utente regularmente, uma vez que favorece a intervenção precoce à fístula arteriovenosa, durante o processo de follow up.

This document will allow the reader to accompany the student in her academic path related to clinical teaching, in the different Nephrology health units. The activities related to the acquisition and development of common and specific skills of the specialist nurse are contemplated by the Nurses Order, (2010; 2011) and defined by the European Dialysis & Transplant Nurses Association / European Renal Care Association - EDTNA / ERCA (Chamney, 2007). A reflection based on the levels of skills acquisition of the Dreyfus model, applied by Benner (2001) to nursing practice, will be written, evidencing, according to Dublin's descriptors, a reflexive practice, with the ability to articulate knowledge in the various multidisciplinary contexts and supported by research elements. According to the internship project, prepared in the preparatory phase, this report will fulfill its objective regarding the topic under study "From pre-construction to the first puncture: The role of the Specialist Nurse in the follow up of the arteriovenous fistula for Hemodialysis", through a scoping review. Mapping scientific evidence to support the importance of follow up, in a vascular consultation nursing consultation. In this sense, the selected articles organize two major areas related to the role of the nurse, the theoretical-practical skills, and the support-education to the user during the different moments of the arteriovenous access. The specialist nurse must be able to dynamize, in health unit, training aspects that enable the acquisition of theoretical and practical skills, and allow them to develop throughout his clinical experience, in a continuous perspective of knowledge sharing among the team of nursing and the user. This theoretical knowledge and practical skills allow nursing care directed at the user with arteriovenous fistula, thus guaranteeing qualified care. Regarding user education support, two areas of attention "access surveillance" and "self-care training" were identified (Sousa, Apóstolo, Figueiredo, Martins & Dias, 2013). The first area encompasses nursing care in the pre and post-construction period of arteriovenous fistula. The area "training self-care" encompasses 4 dimensions: anticipatory care in the preparation of arteriovenous fistula; care within 48 hours after the construction of the arteriovenous fistula; specific care with the arteriovenous fistula maturation process and specific care in a regular hemodialysis program (Sousa et al 2013). The four dimensions mentioned, and Orem's Nursing Self-Care Deficit Theory (2001), thus form a guiding support for nurses regarding the design and application of an intervention plan for the vascular access nursing consultation, during the different moments of the arteriovenous fistula. Through its three theories, the Self-Care Theory, the Self-Care Deficit Theory and the Nursing Systems Theory, its applicability in this context is manifested, as it allows the diagnosis of the knowledge deficit in relation to the arteriovenous fistula, enabling to respond to the self-care requirement, through the support-education system. Thus, the effective involvement of the patient, from the pre-construction to the first puncture, will compromise to perform self-care, reducing anxiety (Mollaoglu, Tuncay, Fertelli & Yürügen, 2012) and benefiting from a positive coping process (Romyn, Rush & Hole, 2015), in the first puncture. It is therefore important to maintain support-education support to the patient regularly, since it favors early intervention for arteriovenous fistula, during the follow up process.

Protecting Restricted Extremities: The Implementation of a Pink Wristband.

Nurses should protect the affected extremities of patients who have a permanent arteriovenous access for hemodialysis by avoiding blood pressure measurements and venipuncture on access extremities. National recommendations include labeling the affected extremity with an alert mechanism, such as a wristband, to notify patients and staff of arteriovenous access. A policy change was enacted at an academic medical center in the Southeast to identify restricted extremities with a pink "limb alert" wristband after review of national recommendations on hemodialysis access preservation, individual facility procedures, product cost-benefit analysis, and unit and system educational methods. Keeping simplicity, nursing workload, and flexibility at the forefront of implementation, evaluation, and process revision, an overall adherence rate of 84.2% was achieved three months after implementation of the policy.

Nursing Care for Patients with Synthetic Arteriovenous Grafts.

Dealing with a growing older adult patient population, keeping pace with current guidelines, and adhering to new recommendations is a perpetual endeavor for healthcare professionals. Because determining the best access for individual patients is not always obvious, vascular access is a challenging aspect of patient care. This article presents information on the ever-evolving and improving world of vascular access, specifically synthetic grafts.

The effect of an educational program for vascular access care on nurses' knowledge at dialysis centers in Khartoum State, Sudan.

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.

Elements of dialysis nursing practice associated with successful cannulation: result of an international survey.

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.

Tattoo of vascular cannulation site as a self-cannulation aid.

BACKGROUND: Haemodialysis can be provided either in a healthcare setting or home environment. Patients receiving dialysis at home report a better quality of life. Patients or their carers must be able to cannulate their fistula confidently and independently when dialysing at home. METHOD: We describe a patient with a functional fistula which was difficult to palpate, leading to difficulties in cannulation and multiple referrals to the home therapies team. PROCEDURE: A series of discrete dots were tattooed to delineate the borders of the fistula and served to guide cannulation. RESULTS: Following this simple intervention, our patient was able to self-cannulate confidently, dialysing at home four times per week. There were no further referrals to the home therapies team. CONCLUSION: Permanent tattoo of the skin to guide cannulation can used when a fistula is difficult to palpate or if a further superficialisation procedure is not desired. Patients have to be made aware that the markings are permanent and might outlast the fistula.

Educación sanitaria a pacientes intervenidos de fístula arteriovenosa / Health education to patients undergoing arteriovenous fistula

Objetivo. Una de las funciones de enfermería es la Educación para la Salud. En este trabajo analizamos la respuesta de los pacientes con insuficiencia renal crónica intervenidos de fístula arteriovenosa ante las intervenciones que planteamos para su autocuidado. Valoramos los conocimientos y entrenamiento adquiridos, así como el grado de satisfacción. Metodología. Realizamos un estudio descriptivo estudiando algunas variables que podían influir en la comprensión, como sexo, edad y lugar de residencia. Trabajamos con una muestra de 80 pacientes a los que se les explicó los cuidados de enfermería que debían aplicar a la fístula arteriovenosa que, después, será utilizada para su hemodiálisis. Se les dio un folleto informativo en el cual se reflejaba dicha información y posteriormente se los llamó por teléfono. Resultados/Conclusiones. Los pacientes manifestaron su utilidad y los resultados observados nos llevan a pensar que la información escrita podría ser un instrumento de refuerzo en la Educación para la Salud, sobre todo en los pacientes de mayor edad, aunque las diferencias en las variables estudiadas no fueron significativas (AU)

Objective. One of the functions of nursing is the Health Education. In this paper we analyze the response of patients with chronic renal failure undergoing arteriovenous fistula to propose interventions for self-care. We value the knowledge and training acquired and satisfaction. Methodology. We develop a descriptive study including some variables that could influence on the understanding, such as sex, age and place of residence. We included a sample of 80 patients who were explained the nursing care to be applied to the arteriovenous fistula for hemodialysis in the future. They were given a booklet with this information reflected and we phoned them after. Results/Conclusions. Patients expressed their usefulness and the results lead us to believe that written information could be instrumental in Health Education reinforcement, especially in older patients, although none of the studied factors show statistical differences (AU)

Evaluación del dolor en la punción de una fístula arteriovenosa para hemodiálisis comparando pomada anestésica frente a frío local / Pain assessment in an arteriovenous fi stule puncture for hemodialysis using anaesthetic cream vs ice

El dolor en pacientes de hemodiálisis no es valorado en su totalidad y no se tiene en cuenta las limitaciones que provoca en la calidad de vida de estos pacientes. Se realizó un estudio observacional analítico, en el que se analizó el grado de dolor al que es sometido el paciente en hemodiálisis cuando se punciona su fístula arteriovenosa. Para ello comparamos el dolor que producía dicha punción si antes utilizábamos uno de estos tres métodos: POMADA ANÉSTESICA (Emla®), PLACEBO (crema hidratante) y HIELO. También hemos evaluado si el método utilizado interfiere en los parámetros de diálisis durante la sesión. Estudiamos a 28 pacientes (23 hombres y 5 mujeres) portadores de fístula. Las variables medidas fueron: dolor (escala EVA), flujo sanguíneo, presión arterial, presión venosa y tiempo de coagulación. Estas variables fueron recogidas durante las tres semanas de duración del estudio (36 sesiones de hemodiálisis) en gráficas. Se analizaron las 36 sesiones de hemodiálisis mediante el uso de una gráfica. Por un lado observamos que el método elegido (Emla®) es estadísticamente significativo (p-valor, p=0.004), por otro lado no existen diferencias significativas entre el método usado y el resto de parámetros recogidos durante la sesión de hemodiálisis (p=0.194, p=0.278, p=0.902, p=0.445). Con respecto al método utilizado los pacientes eligieron como mejor método la Emla® con un 67.86%. Según los datos obtenidos podemos concluir que no existen diferencias estadísticas en las diferentes variables estudiadas. El uso de Emla® obtiene mejor resultado en cuanto al dolor, pero no varía ningún otro parámetro al igual que los otros dos métodos (AU)

Pain in hemodialysis patients is not valued in its entirety and does not take into account the limitations resulting in the quality of life of these patients. We performed an observational study, which analyzed the degree of pain, that suffers a patient undergoing hemodialysis, when is punctured his arteriovenous fistule. To do this we compare the pain that occurred before the puncture if we used one of three methods: anaesthetic cream (Emla ®), PLACEBO (moisturizer)and ICE. We also assessed whether a method interferes dialysis parameters during the session. We studied 28 patients (23 men and 5 women) carrying fistula. The variables measured were pain (VAS), blood flow, blood pressure, venous pressure and clotting time. These variables were collected during the three-week duration of the study (36 sessions of hemodialysis) graphs. 36 were analyzed hemodialysis sessions using a graph on one hand we observed that the used method is statistically significant (p- value, p = 0.004), on the other hand, no significant differences between the used method and the remaining parameters contained in the hemodialysis session (p=0.194, p=0.278, p=0.902, p=0.445). With regard to the used method patients chose as best method Emla ® with 67.86%. According to the data we can conclude that there are no statistical differences in the studied variables. Emla ® using gets better result in terms of pain, but does not change any other parameters like the other two methods (AU)

Interventions to promote self-care of people with arteriovenous fistula.

AIMS AND OBJECTIVES: The literature shows many self-care behaviours related to people with end-stage renal disease (ESRD). Our aim is to identify interventions within the 'teaching' that promote self-care (behaviour) with arteriovenous fistula (AVF). BACKGROUND: The development of self-care behaviours with the AVF allows the access to maintain the best possible conditions, because its state influences the efficacy of the dialysis treatment. However, few studies assess self-care behaviours that people with ESRD have with the AVF, as well as interventions that promote this self-care. DESIGN: Discursive paper. METHODS: Our research was conducted in MEDLINE, Health Nursing and Allied Literature (CINAHL), Web of Science and SCOPUS using three search expressions, between the period of 2000-2010. We selected studies that identified interventions that promote self-care with AVF. RESULTS: No study has shown in detail the interventions that aimed at promoting self-care behaviours with the AVF for patients with ESRD. We verify that the interventions that promote self-care are directed mostly to the moments after AVF construction. CONCLUSIONS: This paper reinforces the need to develop guidelines that provide guidance for self-care with the AVF to be developed by people with ESRD. We also found that self-care behaviours directed to the AVF are mostly associated with postconstruction of the access. RELEVANCE TO CLINICAL PRACTICE: Based on these results, it is necessary to delineate clear intervention programmes and objectives, in order to assess self-care with the AVF by people with ESRD, as well as to develop guidelines that provide guidance for self-care for the person with an AVF.

A review of patients with renal disease undergoing vascular access surgery: is gray-scale ultrasound enough?

BACKGROUND: An adequate fistula or graft is essential to long-term survival and quality of life for patients with end-stage renal disease (ESRD) who are receiving hemodialysis because of its lower complication rates, lower costs, and prolonged patency. Use of duplex ultrasound for preoperative planning is currently recommended by the Kidney Disease Outcomes Quality Initiative for patients with ESRD with prior fistulas or grafts, central lines, pacemakers, and prior chest or arm surgery. The preoperative evaluation consisted of gray-scale ultrasound and physical examination in all patients with ESRD in this study. The current study determined the baseline data, including the type of vascular access, functional patency of access, associated morbidity, and preoperative demographics and comorbidities, including prior dialysis access. The primary objective was to determine the frequency of revision surgery, to identify the potential cases that may indicate the need for better assessments (eg, duplex ultrasound), and to improve fistula and graft success rates. MATERIALS AND METHODS: A retrospective chart review of patients with ESRD who underwent native fistula or graft access creation in a 13-month time period from 2010 to 2011 was completed. Seventy-six surgical procedures were performed on 53 subjects. Included variables were age, race, gender, smoking status, body mass index, stage of chronic kidney disease at referral, previous central lines/pacemakers, fistulas, or grafts. Comorbidities identified included diabetes mellitus (DM), hypertension (HTN), and coronary artery disease (CAD). The types of access, location, maturation, infection, failure, or revision were noted. Continuous variables are shown in frequencies and mean. Categoric data were compared using chi-square analysis. RESULTS: During the 13-month study period, 76 surgical procedures were performed in 53 patients, with 39.6% of patients undergoing multiple surgical procedures. The majority of patients were male (98%) and white (58.5%), with a history of HTN (96.2%) and DM (64.2%). The mean age was 68 years, with most patients presenting in stage 5 chronic kidney disease (92.5%). Some 67.9% of patients had prior central lines or pacemakers; of those, 56.6% had previous fistulas or grafts. Negative significance was determined between the comorbidities DM/HTN/CAD alone or grouped as a cohort and multiple surgeries. Positive significance was found between multiple surgical procedures and those with prior access/pacemaker/central line (chi-square [1, N = 53] = exact P = .04). CONCLUSIONS: Patients with ESRD undergoing access creation presenting with prior central lines, pacemakers, or arm surgery (fistulas or grafts) were more likely to undergo multiple surgeries to obtain a functional graft or fistula for hemodialysis use than those patients with ESRD without prior central lines, pacemakers, or arm surgery (fistulas or grafts). Color duplex ultrasound should be considered as a standard for preoperative assessment in an effort to improve fistula or graft success rates.

Moving beyond the "perpetual novice": understanding the experiences of novice hemodialysis nurses and cannulation of the arteriovenous fistula.

Cannulation of the arteriovenous fistula (AVF) is an essential skill for hemodialysis (HD) nurses. With declining rates of AVFs, opportunities to develop expert cannulation skills have become limited. This study explored the concept of perpetual novice and AVF cannulation from the perspective of the novice cannulator. Nine hemodialysis nurses were interviewed using ethnographic methodology. The study identified the interplay between personal and environmental/contextual factors that hindered skill acquisition. Personal attributes identified by participants included HD nurses' approach to learning and previous experience, emotional reaction to stress, and interpersonal relationships with colleagues. Environmental/contextual factors identified as impediments to cannulation skill development included limited learning opportunities, attitudes and demands from patients, unit flow and time pressures, and limitations imposed by the current model of nursing care. This study will be helpful in directing future educational, operational, and supportive interventions for novice HD nurses around cannulation skill development.

Vascular access graft and native arterial branch fistulous formation.

This is the first reported case of an unusual complication of upper extremity swelling of the arm in a patient with an arteriovenous (AV) graft for haemodialysis. A graftogram demonstrated an aberrant fistula formation between the native arterial branch and the AV graft (aberrant arterio-graft fistula). Inadvertent back wall laceration of the AV graft during haemodialysis cannulation was postulated to be the aetiology. Aberrant arterio-graft fistula formation may be hard to diagnose because of the presence of thrill or bruit at the level of the anastomoses and rarity of the complication. Progression of extremity swelling with or without central venous occlusion should raise the suspicion and sought further investigation. Proper cannulation techniques prior to haemodialysis may prevent such complications.

Almost anyone can have home therapy but can we overcome the barriers?

BACKGROUND: Home dialysis, including both peritoneal and haemodialysis, has been shown to improve patient wellbeing as well as being an economically beneficial alternative to hospital-based therapies. OBJECTIVES: This paper discusses the major barriers to home therapies, particularly in relation to home haemodialysis (HHD) and systems that can be used to overcome them. RESULTS: The use of HHD varies considerably between and within countries. The major limitation is lack of experience and education. A well-planned pre-dialysis education programme seems to be one essential key to the growth of home therapies. CONCLUSIONS: Key points in providing a successful home therapy programme are a highly motivated multidisciplinary team including a dedicated nephrologist and high-level nursing expertise. In addition, an effective pre-dialysis education programme for identifying suitable patients is required.

Successful vascular access management for home haemodialysis: a practical approach.

BACKGROUND: The literature in the field of access management in relation to home haemodialysis (HHD) was reviewed. FINDINGS: One of the greatest benefits of HHD is the possibility for high dose dialysis. There is, however, concern about its adverse effects on access survival. Furthermore, for the patients, self-cannulation is often the biggest obstacle for HHD. Both problems might be resolved by applying a single needle dialysis technique or, in case of arterio-venous fistulae, using the buttonhole (BH) method. As for the BH method there is one limitation-the elevated risk of life-threatening infections. However, in none of the trials referred to in this paper, the BH method was abandoned, probably due to the implementation of successful, problem-tackling measures. CONCLUSION: Continued training and re-training of staff and patients is vital to gain and maintain a wide understanding of successful vascular access management.

A new paradigm: home therapy for patients who start dialysis in an unplanned way.

BACKGROUND: Starting dialysis in a non-planned manner or in a 'suboptimal' manner is a frequent situation in dialysis centres, even for patients with a regular nephrology follow-up. Unplanned dialysis initiation can be defined as a patient beginning dialysis with no functional vascular access or peritoneal dialysis catheter. These patients start haemodialysis with a temporary catheter, frequently converted to a tunnelled catheter pending native fistula creation or whilst waiting for fistula maturation. In this case, conventional in-centre haemodialysis (ICH) is more frequently used than peritoneal dialysis (PD) or home haemodialysis (HHD). REVIEW FINDINGS: This review found that patients who start dialysis in an unplanned way are significantly older and have more heart and peripheral vascular diseases. Home-based dialysis therapies showed better outcomes than ICH (PD for the first two to three years and HHD for the long-term). RECOMMENDATIONS: This review proposes a paradigm shift in the initial form of dialysis offered to new patients starting dialysis in an unplanned way. Even if they require a temporary catheter, it is possible for them to receive a pre-dialysis education programme (PDEP). The PDEP should be based on both individualised information session(s) given by an experienced nurse to the patient and family and therapeutic education (educative diagnosis, individualised and group session(s)) in order to relieve anxiety and promote home modalities.

Education in vascular access.

The successful creation and use of an arteriovenous vascular access (VA) requires a coordinated, educated multidisciplinary team to ensure an optimal VA for each patient. Patient education programs on VA are associated with increased arteriovenous VA use at dialysis initiation. Education should be tailored to patient goals and preferences with the understanding that experiential education from patient to patient is far more influential than that provided by the healthcare professional. VA education for the nephrologist should focus on addressing the systematic and patient-level barriers in achieving a functional VA, with specific components relating to VA creation, maturation, and cannulation that consider patient goals and preferences. A deficit in nursing skills in the area of assessment and cannulation can have devastating consequences for hemodialysis patients. Delivery of an integrated education program increases nurses' knowledge of VA and development of simulation programs or constructs to assist in cannulation of the VA will greatly facilitate the much needed skill transfer. Adequate VA surgical training and experience are critical to the creation and outcomes of VA. Simulations can benefit nephrologists, dialysis nurses surgeons, and interventionalists though aiding in surgical creation, understanding of the physiology and anatomy of a dysfunctional VA, and practicing cannulation techniques. All future educational initiatives must emphasize the importance of multidisciplinary care to attain successful VA outcomes.