Management Approaches to Stomal and Peristomal Complications: A Narrative Descriptive Study.

PURPOSE: The purpose of this study was to identify optimal interventions for selected complications based on WOC nurse experts' judgment/expertise. METHODS: A cross-sectional quantitative descriptive design with qualitative, narrative-type components was used for this study. Following validation rating of appropriateness of interventions and quantitative rankings of first-, second-, and third-line approaches, participants provided substantive handwritten narrative comments about listed interventions. Comments were organized and prioritized using frequency count. RESULTS: Narrative comments reflected the quantitative rankings of efficacy of approaches. Clinicians offered further specific suggestions regarding product use and progression of care for selected complications. CONCLUSIONS: Narrative analysis using descriptive quantitative frequency count supported the rankings of most preferred treatments of selected stomal and peristomal complications. Findings add to the previous research on prioritized approaches and evidence-based practice in ostomy care.

Punción del acceso vascular mediante catéter-fístula: efecto sobre el dolor del paciente y la adecuación de hemodiálisis / Vascular access puncture using fistula catheter: effect on the patient´s pain and adequacy of hemodialysis

Introducción: El uso de los nuevos diseños de agujas para la punción del acceso vascular puede mejorar la calidad de vida de los pacientes y los parámetros de eficacia hemodiálisis. Objetivos: Evaluar si hay diferencias en la intensidad del dolor percibido por los pacientes y la adecuación de hemodiálisis (índice Kt) después de la punción de la fístula arteriovenosa interna humeral a través de catéter-fístula o aguja estándar. Pacientes y métodos: Se realizó un estudio controlado, prospectivo, randomizado durante 4 meses (48 sesiones) para comparar la punción con catéter fistula (casos) versus a aguja estándard (controles) en pacientes en hemodiálisis prevalentes dializados por fístula arteriovenosa humeral. El mismo paciente era el caso y el control cuando se utilizó el catéter fístula (24 sesiones) y la aguja estandard de calibres equivalentes 15G (24 sesiones), respectivamente. El catéter fístula es una cánula de punción biocompatible compuesto por una aguja de metal interna destinado al pinchazo de la fístula humeral y un catéter de fluroplastico externa, de calibre15G, que permanece en el interior de la vena arterializada. El dolor relacionado, ya sea con punción o con la retirada de la aguja, se cuantificó mediante una escala validada visual analógica (EVA) y la escala McGill Pain Questionnaire Short Form (SF-MPQ). Resultados: Analizamos 14 pacientes prevalentes en hemodiálisis (edad media 68,4 ± 10,43 años; 71% hombres; 28,6% nefropatía diabética, tiempo medio en hemodiálisis 36,57 ± 18,28 meses) a través de fístula humerocefalica (50%), humerobasilica (21%) o humeroperforante (29%). Durante la punción y despunción de la fístula humeral, la EVA fue significativamente menor para el catéter fístula (2,07 ± 0,73 y 0,76 ± 0,39) en comparación con AS (2,88 ± 0,99 y 1,85 ± 0,95) (para ambas comparaciones, p <0,001). No se encontraron diferencias significativas en la escala SF-MPQ durante la sesión de hemodiálisis entre catéter fístula y aguja estandard (0,03 ± 0,07 frente a 0,11 ± 0,26, p = 0,13). La presión venosa (mmHg) registrada durante la primera y la última hora de la sesión de hemodiálisis fue significativa inferior para catéter fístula (171,2 ± 15,5 y 174,4 ± 16,7) en comparación con aguja estandard (194.9 ± 15.1 y 198.0 ± 20.1) (para ambas comparaciones, p <0,001). El índice Kt obtenido fue significativamente mayor para catéter fístula (51,1 ± 3,6 L) en comparación con aguja estandard (48,4 ± 3,1 L) (con p <0,001). No hubo episodios de extravasación con el catéter fístula y sólo uno con la aguja estandard (p = NS). Conclusiones: En relación con la aguja estandard, la utilización del catéter fístula disminuye el dolor percibido durante la punción o la retirada de la aguja (escala analógica visual), y la mejora la adecuación de la hemodiálisis (índice Kt) (AU)

Introduction: The use of new needle designs for VA puncture may improve the quality of life of patients (pts) and the parameters of HD efficacy. Objectives: To evaluate whether there are differences in the intensity of the pain perceived by the pts and HD adequacy (Kt Index) after brachial arteriovenous fistula (AVF) puncture through catheter-fistula (CF) or standard needling (SN). Patients and methods: We performed a prospective, controlled, nonrandomized study during 2 months (24 HD sessions) to compare needling by CF (cases) versus SN (controls) in prevalent HD pts dialyzed by brachial AVF. The same patient was the case and the control when the CF (12 sessions) and the conventional 15G needle (12 sessions) were used, respectively. The CF is a biocompatible puncture cannula composed by an internal metal needle intended to AVF puncture and an external fluroplastic catheter (15G) that remains inside the arterialized vein. The pain related either with needling or with needle withdrawal was quantified using a validated visual analogue scale (VAS) and the Short-Form McGill Pain Questionnaire (SF-MPQ). Results: We analyzed 14 prevalent HD pts (mean age 68.4 +/- 10.43 years; 71% male; 28.6 % diabetic nephropathy; mean time on HD 36.57 +/- 18.28 months) dialyzed by brachiocephalic (50%), brachiobasilic (21%) or brachioperforating (29%) fistula. During both needling and needle withdrawal, the VAS was significant lower for CF (2.07 +/- 0.73 and 0,76 +/- 0,39) compared to SN (2.88 +/- 0.99 and 1.85 +/- 0.95) (for both comparisons, p < 0,001). No significant difference was found when comparing the SF-MPQ score during HD session between CF and SN (0.03 +/- 0.07 versus 0.11 +/- 0.26, p = 0.13). The venous pressure (mmHg) recorded during the first and last hour of HD session was significant lower for CF (171.2 +/- 15.5 and 174.4 +/- 16.7) compared to SN (194.9 +/- 15.1 and 198.0 +/- 20.1) (for both comparisons, p < 0,001). The Kt index obtained was significantly higher for CF (51,1 +/- 3,6 L) compared to SN (48.4 +/- 3,1 L) (p < 0.001). No AVF leakage episodes were recorded with CF and only one by SN (p = NS). Conclusions: In relation to the standard needle, the use of fistula catheter decreases perceived pain in the puncture and removal of the needle (visual analog scale), and improving the adequacy of hemodialysis (Kt index) (AU)

Monitorización del acceso vascular: parámetros convencionales frente a flujo intraacceso / Vascular access monitoring: conventional parameters versus intra-access flow

Mantener la permeabilidad de los accesos vasculares es un objetivo capital en el paciente en hemodiálisis. Los parámetros clásicos de monitorización del acceso vascular son en general tardíos para la detección de estenosis. El cálculo del flujo intraacceso es un método de segunda generación que permite conocer el flujo sanguíneo máximo del acceso así como detectar estenosis ante una disminución del mismo. El objetivo de este estudio es valorar la eficacia de la medición y vigilancia del flujo intraacceso frente a los parámetros clínicos de primera generación. Mensualmente se realiza monitorización del acceso vascular registrando variables del examen físico y del examen dinámico. La determinación de flujo intraacceso se realiza trimestralmente en FAV y mensualmente en PPTFE. Se indica realización de fistulografía si el flujo intraacceso es menor de 500ml/min o disminución en un 20% confirmado en dos tomas consecutivas, si hay variaciones en la exploración física y disminución ≥ 25% de Kt, flujo sanguíneo o aumento de presiones venosas o recirculación. Se realizan 61 fistulografías. Se hallan diferencias significativas por método de valoración (p<0,001) así como diferencias significativas en falsos positivos (fistulografía blanca o estenosis < 50%) (p=0,024). La monitorización del flujo intraacceso es un método altamente sensible de detección de disfunción del acceso vascular. La combinación de parámetros clínicos, clásicos y el flujo intraacceso en un programa de monitorización del acceso vascular permite detectar más del 80% de los casos confirmados por fistulografía (AU)

It is a major goal in hemodialysis patient to maintain permeable vascular access. Classic parameters for monitoring the vascular access are generally slow to detect stenosis. Intra-access flow calculation is a second-generation method that allows knowing the maximum access blood flow and to detect stenosis when there is a decreased flow. The aim of this study is to assess the efficacy of the measurement and monitoring of intra-access flow compared to first-generation clinical parameters. Vascular access monitoring is done monthly, recording the physical and dynamic examination variables. The determination of intra-access flow is performed quarterly in AVF and monthly in PTFE. Fistulography is recommended if the intra-access flow is less than 500 ml / min or a decrease by 20% confirmed on two consecutive measurements, or if there are variations in the physical examination and Kt decreased by over 25%, blood flow or increased venous pressure or recirculation. 61 fistulographies were performed. Significant differences by valuation method (p <0.001) and in false positives (stenosis <50%) (p = 0.024) was found. Intra-access flow monitoring is a highly sensitive method for detection of vascular access dysfunction. The combination of clinical, classical parameters and intra-access flow in a monitoring program for vascular access, can detect more than 80% of confirmed cases by fistulography (AU)

O cuidar e os cuidados de enfermagem ao cliente com fístula faringocutânea: o resgate da esperança no enfrentamento das necessidades / The give care and the nursing cate to the client with pharyngocutaneous fistula: the sanson of the hope in the needs confrontation

Estudo qualitativo do tipo exploratório e descritivo, tendo como etnométodo, a etnografia. Objeto de estudo: o cuidar e os cuidados do cliente com fístula faringocutânea (FFC). Objetivos: - descrever as (re) ações comportamentais do cliente às situações impostas pela FFC; - identificar as necessidades no cotidiano destes clientes para a construção do cuidare dos cuidados de enfermagem a partir dos mesmos; - construir um Jornal de Cuidados para o cliente, a partir das necessidades que emergirem da pesquisa, como subsídio para oresgate da esperança. O referencial teórico: Teoria do Cuidado Humano de Jean Watson, a Teoria da Esperança de Jerome Groopman, a Teoria da Esperança de Milton Mayeroff e asconcepções teóricas de outros estudiosos destas temáticas. Participaram do estudo, 12 (doze) sujeitos cujo critério de inclusão foi: serem clientes adultos, lúcidos, com FFC, que receberam alta hospitalar médica, mas que não receberam alta dos cuidados de enfermagem, que estavam vivenciando o processo de transição hospital/casa. Cenários do estudo: Ambulatórios de Cirurgia de Cabeça e Pescoço do Hospital do Câncer I doInstituto Nacional do Câncer (INCA) e do Hospital Geral de Bonsucesso, do Ministério da Saúde, ambos no Município do Rio de Janeiro....

The community management of chylous fistula using a pancreatic lipase inhibitor (orlistat).

We describe two innovative ideas in the treatment of iatrogenic chyle leak. The first is the early use of a pancreatic lipase inhibitor (Orlistat) to reduce fat absorption and chyle production, with consequent faster fistula healing. The second is the treatment of these patients at home in the community by district nurses backed by the hospital staff. This domiciliary approach has a positive psychological effect on the patient, permits the patient to take responsibility for their treatment, and reduces hospital length of stay minimising patient exposure to nosocomial infections.

Pasado, presente y futuro de la unidad de estomaterapia del Hospital Clínico San Carlos / Past, present and future of stomatherapy unit of Hospital Clinico San Carlos

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Stoma care accessories: an overview of a crowded market.

While many stomas do not develop any problems, up to 55% of them do. Stoma accessories are often used to either prevent stoma problems or resolve them, but there is a potentially baffling array of products available. This article provides an overview of the accessories currently available, to assist the community nurse in the care of patients with stomas.

Cost-effective management of pharyngocutaneous fistulas following laryngectomy.

A pharyngocutaneous fistula following a total laryngectomy is not an uncommon occurrence. The incidence of this serious complication ranges worldwide from 7.6 percent to 50 percent. It usually exacerbates post-operative morbidity and increases expense with prolonged hospitalization. This complication often requires additional operative procedures or if untreated may lead to a fatal complication such as carotid artery rupture. There are multiple predisposing factors leading to poor wound healing in this patient population. These factors include prior radiation therapy, chemotherapy, compromised nutrition, and associated surgical procedures including radical neck dissection. A treatment strategy for difficult fistulas with undermining is presented here. The cornerstones of this approach include opening the area large enough for packing and cleansing, diverting the copious pharyngeal secretions and providing an optimal wound environment through the use of an amorphous hydrogel dressing (Intrasite* Gel, Smith & Nephew United, Inc., Largo, FL). This treatment strategy led to complete and sustained healing when utilized by the authors in the following patients. It was successful even in heavily irradiated tissue with its severe changes of compromised vascularity, increased dermal fibrosis and epidermal thinning. The authors have found this technique a cost-effective alternative to secondary surgery, applicable in both the acute and home care settings.

[Skin care in digestive fistulae]. / Cuidados com a pele em fístulas digestivas.

The author approaches about historical aspects, concepts, etiology and treatment of digestive fistula. The skin care and drainage control are the basis of stomal therapy. So, the author discusses the specific nursing and ET care in this subject, including evaluation, procedures and resources.

Caring for patients with enterocutaneous fistulae.

Fistulae are distressing for both patients and staff. The management of fistulae presents a challenge to the nurse in terms of providing care for the psychological and physiological needs of the patient. This article describes the causes of fistulae and examines the nursing priorities and how to achieve them.