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Pontes D, Munari DB, Costa DDM, Pereira PPDS, Sousa ET, Tipple AFV. Quality indicators for the processing of health products: A mixed-methods study. Rev Lat Am Enfermagem 2024; 32:e4134. [PMID: 38655935 DOI: 10.1590/1518-8345.6766.4134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 11/30/2023] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE to analyze the use of quality assessment indicators and their implementation to improve quality in the processing of health products. METHOD a mixed-methods study with a multiple case approach using Structure, Process and Results indicators and elaboration of a plan using Appreciative Inquiry, carried out in four central sterile supply departments from hospital units. RESULTS the indicators for the Cleaning stage presented 47.8% compliance for Structure and 59.0% for Process: in addition 71.8% of the products were clean. In the Preparation operational stage, 50.0% of the Results indicators were in compliance for Structure and 66.7% for Process. In the Sterilization, Storage and Distribution stage, 43.5% compliance was obtained for Structure, 55.7% for Process and 78.6% for Packaging conservation. Appreciative planning proposed improvements to the physical structure, review of processes and protocols, promotion and appreciation of the work done and strengthening of teaching about processing and service management, highlighting the protagonism of the group and of the leaders. CONCLUSION using indicators was positive in materializing reality; however, it was verified that the improvements proposed are related to people. The affirmative and constructive view of Appreciative Inquiry presented itself as a path to changes and quality improvements.
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Affiliation(s)
- Daniela Pontes
- Universidade Federal de Rondônia, Departamento de Enfermagem, Porto Velho, RO, Brazil
| | | | | | | | - Elyana Teixeira Sousa
- Universidade Federal de Mato Grosso, Instituto Federal de Saúde Pública, Cuiabá, MT, Brazil
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Meng L, Ng JJ, Choong AMTL, Dharmaraj RB, Menon R, Wong JCL, Ching S, Wong YF, Kong J, Ho P. Effectiveness of a native vein arteriovenous fistula tracking system. Semin Dial 2024; 37:161-171. [PMID: 37748774 DOI: 10.1111/sdi.13179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/30/2023] [Accepted: 09/10/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE This study aims to evaluate the effectiveness of a tracking program on the functional maturation rate of arteriovenous fistula (AVF). METHODS Two major clinical outcomes (commencement of cannulation and functional maturation) of created AVFs were compared between two cohorts. (i) Cohort 1: historical cohort; (ii) Cohort 2: AVFs created after implementation of the tracking project. Multivariable Cox regression models were used to assess the association between cohort allocation and the two major clinical outcomes. RESULTS Data of 114 and 141 patients were analyzed respectively from Cohorts 1 (historical data) and 2 (with AVF tracking). After adjustment of covariates in the multivariable analysis, the AVFs created in Cohort 2 were more likely to be cannulated earlier (adjusted HR: 2.82; 95% CI: 1.97-4.05; p < 0.001), compared to those in Cohort 1. Similarly, the AVFs of Cohort 2 patients had significantly higher probability of functional maturation (adjusted HR: 1.81; 95% CI: 1.31-2.48; p < 0.001) than fistulas in Cohort 1. Cannulation was commenced for half of the AVFs by 4.1 months post-creation in the historical cohort (Cohort 1), whereas in the post-tracking cohort, 50% of the AVFs were cannulated by 2.3 months after creation (p < 0.001). It took 5.5 and 4.3 months for 50% of the AVFs created in Cohort 1 and Cohort 2 patients to achieve catheter-free functional maturation, respectively (p = 0.06). CONCLUSION An AVF tracking program with maturation target for the access surgeons, together with a standardized tracking, feedback, and clinical strategy adjustment system is able to improve the AVF functional maturation rate.
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Affiliation(s)
- Lingyan Meng
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Jun Jie Ng
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Andrew Mark Tze Liang Choong
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Rajesh Babu Dharmaraj
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Raj Menon
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Julian Chi Leung Wong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Susan Ching
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Yen Feng Wong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Jaqueline Kong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Pei Ho
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
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Hudson R, Pascoe EM, See YP, Cho Y, Polkinghorne KR, Paul-Brent PA, Hooi LS, Ong LM, Mori TA, Badve SV, Cass A, Kerr PG, Voss D, Hawley CM, Johnson DW, Irish AB, Viecelli AK. A comparison of arteriovenous fistula failure between Malaysian and Australian and New Zealand participants enrolled in the FAVOURED trial. J Vasc Access 2024; 25:193-202. [PMID: 35686506 DOI: 10.1177/11297298221099134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIM To describe and compare de novo arteriovenous fistula (AVF) failure rates between Australia and New Zealand (ANZ), and Malaysia. BACKGROUND AVFs are preferred for haemodialysis access but are limited by high rates of early failure. METHODS A post hoc analysis of 353 participants from ANZ and Malaysia included in the FAVOURED randomised-controlled trial undergoing de novo AVF surgery was performed. Composite AVF failure (thrombosis, abandonment, cannulation failure) and its individual components were compared between ANZ (n = 209) and Malaysian (n = 144) participants using logistic regression adjusted for patient- and potentially modifiable clinical factors. RESULTS Participants' mean age was 55 ± 14.3 years and 64% were male. Compared with ANZ participants, Malaysian participants were younger with lower body mass index, higher prevalence of diabetes mellitus and lower prevalence of cardiovascular disease. AVF failure was less frequent in the Malaysian cohort (38% vs 54%; adjusted odds ratio (OR) 0.53, 95% confidence interval (CI) 0.31-0.93). This difference was driven by lower odds of cannulation failure (29% vs 47%, OR 0.45, 95% CI 0.25-0.80), while the odds of AVF thrombosis (17% vs 20%, OR 1.24, 95% CI 0.62-2.48) and abandonment (25% vs 23%, OR 1.17, 95% CI 0.62-2.16) were similar. CONCLUSIONS The risk of AVF failure was significantly lower in Malaysia compared to ANZ and driven by a lower risk of cannulation failure. Differences in practice patterns, including patient selection, surgical techniques, anaesthesia or cannulation techniques may account for regional outcome differences and warrant further investigation.
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Affiliation(s)
- Rebecca Hudson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Yong Pey See
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Peta-Anne Paul-Brent
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Lai-Seong Hooi
- Haemodialysis Unit, Department of Medicine, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| | - Loke-Meng Ong
- Department of Nephrology, Penang Hospital, George Town, Malaysia
| | - Trevor A Mori
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Sunil V Badve
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Nephrology, St George Hospital, Sydney, NSW, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Medical Centre, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - David Voss
- Middlemore Renal Services, Middlemore Hospital, Auckland, New Zealand
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - Ashley B Irish
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Nephrology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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Fielding C, Bramley L, Stalker C, Brand S, Toft S, Buchanan H. Patients' experiences of cannulation of arteriovenous access for haemodialysis: A qualitative systematic review. J Vasc Access 2023; 24:1121-1133. [PMID: 35034481 PMCID: PMC10631276 DOI: 10.1177/11297298211067630] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/27/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Cannulation is an essential part of haemodialysis with arteriovenous access. Patients' experiences of cannulation for haemodialysis are problematic but poorly understood. This review aims to synthesise findings related to patients' experiences of cannulation for haemodialysis from qualitative studies, providing a fuller description of this phenomenon. METHODS Eligibility criteria defined the inclusion of studies with a population of patients with end-stage kidney disease on haemodialysis. The phenomena of interest was findings related to patients' experiences of cannulation for haemodialysis and the context was both in-centre and home haemodialysis. MedLine, CINAHL, EMBASE, EMCARE, BNI, PsycInfo and PubMed were last searched between 20/05/2019 and 23/05/2019. The quality of studies was assessed using the using Joanna Briggs Critical Appraisal Checklist for Qualitative Research. Meta-aggregation was used to synthesise findings and CERQual to assess the strength of accumulated findings. RESULTS This review included 26 studies. The subject of included studies covered cannulation, pain, experiences of vascular access, experiences of haemodialysis and a research priority setting exercise. From these studies, three themes were meta-aggregated: (1) Cannulation for haemodialysis is an unpleasant, abnormal and unique procedure associated with pain, abnormal appearance, vulnerability and dependency. (2) The necessity of cannulation for haemodialysis emphasises the unpleasantness of the procedure. Success had multiple meanings for patients and patients worry about whether the needle insertion will be successful. (3) Patients survive unpleasant, necessary and repetitive cannulation by learning to tolerate cannulation and exerting control over the procedure. Feeling safe can help them tolerate cannulation better and the cannulator can invoke feeling safe. However, some patients still avoid cannulation, due to its unpleasantness. CONCLUSIONS Cannulation is a pervasive procedure that impacts on patients' experiences of haemodialysis. This review illuminates further patients' experiences of cannulation for haemodialysis, indicating how improvements can be made to cannulation. REGISTRATION PROSPERO (CRD42019134583).
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Affiliation(s)
- Catherine Fielding
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Louise Bramley
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Sarah Brand
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Suzanne Toft
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Pinto R, Ferreira E, Sousa C, Barros JP, Correia AL, Silva AR, Henriques A, Mata F, Salgueiro A, Fernandes I. Skin pigmentation as landmark for arteriovenous fistula cannulation in hemodialysis. J Vasc Access 2023:11297298231193477. [PMID: 37596950 DOI: 10.1177/11297298231193477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND The cannulation of the arteriovenous fistula (AVF) for hemodialysis (HD) has traditionally depended on the nurse's tactile sensation, which has been associated with suboptimal needle placement and detrimental effects on vascular access (VA) longevity. While the introduction of ultrasound (US) has proven beneficial in mapping the AVF outflow vein and assisting in cannulation planning, aneurysmal deformations remain a common occurrence resulting from various factors, including inadequate cannulation techniques. Within this context, the utilization of skin pigmentation as a clinical landmark has emerged as a potential approach to enhance cannulation planning in HD. METHODS A prospective longitudinal study was undertaken to investigate the correlation between the occurrence of venous morphological deformations and the cannulation technique guided by skin pigmentation after a 2-month period of implementation. RESULTS Thirty patients were enrolled in the study with 433 cannulations being described within the first 2 months of AVF use. The overall rate of cannulation-related adverse events was 21.9%. Comparative analysis demonstrated a statistically significant relationship (p < 0.001) between aneurysmal deformation and non-compliance with the proposed cannulation technique, resulting in cannulation outside the designated points. Non-compliance was primarily attributed to nurse's decision (57.1%). CONCLUSION The integration of US mapping of the AVF outflow vein and the utilization of skin pigmentation as a guiding tool have shown promising results in enhancing cannulation planning over time. Consistent adherence to a cannulation technique other than the area technique has been found to reduce the risk of AVF morphological deformation. These findings underscore the potential benefits of incorporating skin pigmentation as a clinical landmark in cannulation practices, highlighting its ability to impact positively cannulation outcomes.
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Affiliation(s)
- Rui Pinto
- Dialysis Unit-Nephrology, University Hospital Center, Coimbra, Portugal
| | - Emanuel Ferreira
- Dialysis Unit-Nephrology, University Hospital Center, Coimbra, Portugal
| | - Clemente Sousa
- Center for Health Technology and Services Research Faculty of Medicine, Porto University, Porto, Portugal
| | | | - Ana Luísa Correia
- Dialysis Unit-Nephrology, University Hospital Center, Coimbra, Portugal
| | - Ana Rita Silva
- Dialysis Unit-Nephrology, University Hospital Center, Coimbra, Portugal
| | - Andreia Henriques
- Dialysis Unit-Nephrology, University Hospital Center, Coimbra, Portugal
| | - Fernando Mata
- Dialysis Unit-Nephrology, University Hospital Center, Coimbra, Portugal
| | - Anabela Salgueiro
- Health Sciences Research Unit: Nursing-Nursing School Coimbra, Coimbra, Portugal
- Portuguese Vascular Access Association, Coimbra, Portugal
| | - Isabel Fernandes
- Health Sciences Research Unit: Nursing-Nursing School Coimbra, Coimbra, Portugal
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Zhang Z, Petersen L, Bible J, Geissler J, Roy-Chaudhury P, Brouwer-Maier D, Singapogu R. Needle Angle Matters: An Investigation of the Effect of Needle Angle on Hemodialysis Cannulation Skill. Kidney360 2023; 4:962-970. [PMID: 37254250 PMCID: PMC10371289 DOI: 10.34067/kid.0000000000000163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/13/2023] [Indexed: 06/01/2023]
Abstract
Key Points Three metrics that quantify cannulation skill on the basis of needle angle are introduced. All three needle angle metrics were demonstrated to be useful in predicting cannulation outcomes on the simulator. Background Cannulation is critical for maintaining a functional vascular access for patients on hemodialysis. However, relatively little is known about the quantitative aspects of needle insertion dynamics required for skilled cannulation. In this article, we introduce three kinds of metrics that quantify needle insertion angle—recognized as important for safe and effective cannulation—during cannulation on an instrumented simulator for skill assessment. Three questions were examined in this study: (1 ) Are simulator-based needle angle metrics related to cannulation success? (2 ) Are needle angle metrics related to simulated blood flashback quality? and (3 ) Can needle angle metrics be used to distinguish between high and low skill levels? Methods Fifty-one cannulators with varying degrees of clinical experience performed cannulation on the instrumented simulator. Each participant cannulated 16 times on different fistulas with varying geometries. During each trial, needle angle along with other sensor data was obtained through a motion sensor placed inside the needle. Data analysis was conducted by relating needle angle over time with our previously validated simulator-based cannulation outcome metrics. Results The results revealed that all three types of needle angle metrics were useful in predicting the probability of cannulation success. In addition, they were also correlated with flashback quality metrics. Furthermore, these metrics successfully distinguished between high and low performers regardless of whether they were classified using subjective ratings or objective scores. These results indicate that needle insertion angle is an important component of cannulation skill. Conclusions The simulator-based metrics for needle insertion angle presented in this work measure a key aspect of skilled cannulation. As such, if implemented in a structured way, these metrics could lead to competency-based skill assessment and training for cannulation in the future. Raising the bar of cannulation skill of our clinicians can have a tangible effect on patient outcomes.
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Affiliation(s)
- Ziyang Zhang
- Department of Bioengineering, Clemson University, Clemson, South Carolina
| | - Lydia Petersen
- Department of Bioengineering, Clemson University, Clemson, South Carolina
| | - Joe Bible
- School of Mathematical and Statistical Sciences, Clemson University, Clemson, South Carolina
| | - Judy Geissler
- Williams S Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Prabir Roy-Chaudhury
- UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina
- (Bill Hefner) VA Medical Center, Salisbury, North Carolina
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Chen S, Liu JS, Chai CC, Si C, Tan SH, Ravindran HR, Martinez MTP, Gao Y, Yeap YR, Liu AYL. Handheld ultrasound-guided cannulation of difficult hemodialysis arteriovenous access: A randomized controlled trial. Hemodial Int 2023; 27:21-27. [PMID: 36281908 DOI: 10.1111/hdi.13050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Cannulation of complex arteriovenous fistula (AVF) or graft (AVG) frequently poses challenges to renal nursing practice. Ultrasound (US) guidance on visualizing central and peripheral venous access has been widely adopted in nephrology, reducing vascular intervention complications. Renal nurses could acquire this point-of-care technique to increase the successful cannulation rate while facilitating confidence build-up during practice. We aim to evaluate the use of handheld US on difficult AVF/AVG cannulation in a hospital-based dialysis unit. METHODS We conducted a single-center randomized controlled trial from January 2021 to January 2022. Ten renal nurses were trained by an interventional nephrologist before patient recruitment and had completed a pre- and posttraining questionnaire on their confidence level. Fifty hemodialysis patients with complex AVF were randomized to US-guided or conventional cannulation. The total time spent on cannulation and patients' pain scores were also collected. FINDINGS Renal nurses increased their confidence level after training (pretraining score 26.6 ± 6.9 vs. posttraining score 36.4 ± 3.0; p = 0.014). There was a higher success rate (only one cannulation attempt required) for US-guided (96%) versus conventional (72.0%) cannulation (p = 0.049). US-guided cannulation had a lower pain score than the conventional method (1.48 ± 0.73 vs. 2.13 ± 0.95, p = 0.012). The pre-cannulation assessment time and time spent on cannulation were comparable between the two groups. DISCUSSION Our study showed that US-guided cannulation increased renal nurses' confidence level in difficult cannulation and improved success rate. Larger scale studies are required to further assess the applications of handheld US in AVF cannulation, particularly in different clinical settings (e.g., chronic dialysis centers).
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Affiliation(s)
- Shune Chen
- Renal Centre, Khoo Teck Puat Hospital, Singapore, Singapore
| | | | - Chung Cheen Chai
- Division of Renal Medicine, Department of Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Chanjuan Si
- Renal Centre, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Si Hui Tan
- Renal Centre, Khoo Teck Puat Hospital, Singapore, Singapore
| | | | | | - Yang Gao
- Renal Centre, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Ying Ru Yeap
- Renal Centre, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Allen Yan Lun Liu
- Division of Renal Medicine, Department of Medicine, Khoo Teck Puat Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Staaf K, Fernström A, Uhlin F. How to needle: A mixed methods study on choice of cannulation technique for arteriovenous fistula. J Clin Nurs 2022. [PMID: 35811391 DOI: 10.1111/jocn.16454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 05/31/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES The aim of this study was to describe the basis for choosing a cannulation technique for arteriovenous fistula. BACKGROUND Four cannulation techniques are relevant to cannulating an arteriovenous fistula: rope ladder, area puncture and buttonhole using blunt or sharp needles. The chosen technique may affect both the patency and number of complications. DESIGN The study used a convergent mixed methods design and inductive approach. METHODS A questionnaire and an inquiry of local guidelines were sent to nurses in all dialysis units in Sweden. Questionnaires were answered by nurses from 37 units, and 29 units included their local guidelines. The questionnaires were analysed using descriptive statistics and qualitative content analysis, and the guidelines were analysed using qualitative content analysis. The different analyses were combined in a final result. The study is based on GRAMMS guidelines. RESULTS Local guidelines, patients' and nurses' own judgement, and consultation with colleagues were found to greatly influence the choice of cannulation technique. Buttonhole was the most preferred cannulation technique in the participating units and was favoured by nurses when choosing a cannulation technique. The process of choosing a cannulation technique was found to be influenced by the dedication to good cannulation technique and healthy arteriovenous fistulas, whether the technique is perceived as being easy to use and is expected to prevent complications and based on the experienced-based knowledge of each dialysis unit. CONCLUSIONS Choosing a cannulation technique is a process based on the nurse, local guidelines and the patient. Most dialysis nurses and units in Sweden consider buttonhole to be a good cannulation technique and use it as their standard technique. RELEVANCE TO CLINICAL PRACTICE The results provide insight into why cannulation techniques are chosen differently in different units. The results also show the importance of evidence in making decisions on cannulation technique.
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Affiliation(s)
- Karin Staaf
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Nephrology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Anders Fernström
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Nephrology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Fredrik Uhlin
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Nephrology, Linköping University Hospital, Region Östergötland, Linköping, Sweden.,Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
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Murea M, Woo K. New Frontiers in Vascular Access Practice: From Standardized to Patient-tailored Care and Shared Decision Making. Kidney360 2021; 2:1380-1389. [PMID: 35369664 PMCID: PMC8676387 DOI: 10.34067/kid.0002882021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/07/2021] [Indexed: 02/04/2023]
Abstract
Vascular access planning is critical in the management of patients with advanced kidney disease who elect for hemodialysis for RRT. Policies put in place more than two decades ago attempted to standardize vascular access care around the model of optimal, namely arteriovenous fistula, and least preferred, namely central venous catheter, type of access. This homogenized approach to vascular access care emerged ineffective in the increasingly heterogeneous and complex dialysis population. The most recent vascular access guidelines acknowledge the limitations of standardized care and encourage tailoring vascular access care on the basis of patient and disease characteristics. In this article, we discuss available literature in support of patient-tailored access care on the basis of differences in vascular access outcomes by biologic and social factors-age, sex, and race. Further, we draw attention to the overlooked dimension of patient-reported preferences and shared decision making in the practice of vascular access planning. We discuss milestones to overcome as requisite steps to implement effective shared decision making in vascular access care. Finally, we take into consideration local practice cofactors as major players in vascular access fate. We conclude that a personalized approach to hemodialysis vascular access will require dynamic care specifically relevant to the individual on the basis of biologic factors, fluctuating clinical needs, values, and preferences.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Karen Woo
- Department of Surgery, University of California Los Angeles, Los Angeles, California
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Kosmadakis G, Amara B, Costel G, Lescure C. Pain associated with arteriovenous fistula cannulation: Still a problem. Nephrol Ther 2021; 18:59-62. [PMID: 34148807 DOI: 10.1016/j.nephro.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 11/30/2022]
Abstract
CONTEXT Puncture-related pain during arteriovenous fistula cannulation is a crucial influential factor in the quality of life of chronic hemodialysis patients. OBJECTIVES/METHODS In this prospective single center study, we used a questionnaire to evaluate the patterns of pain of arteriovenous fistula cannulation in a group of hemodialysis patients. RESULTS From a total of 123 eligible patients with arteriovenous fistula invited to participate, 83 (58 M/25 F) (median age 58 y.o.) returned questionnaires. Sixty-five benefitted from an analgesic intervention on cannulation, and 62 found this intervention effective. We evaluated the pain intensity with the échelle visuelle analogique score, the equivalent of Visual Analogue Scale score in French. No specific analgesic intervention (lidocaine patch or cream, vapocoolant spray) was more effective than the others (pNS). 30/65 patients with and 10/18 patients without analgesic intervention reported pain on cannulation (échelle visuelle analogique>1) (pNS). 21/65 patients with and 6/18 patients without analgesic intervention reported pain on needle retraction (pNS). Forty of the 65 patients with analgesic intervention and 11/18 patients without intervention feel stressed before each cannulation. The stress of arteriovenous fistula-related pain is significantly associated with a sensation of pain on cannulation (P=0.047) and needle retraction (P=0.002). CONCLUSION Despite prophylactic measures for arteriovenous fistula cannulation pain, patients frequently experience stress and unpleasant sensations associated with the procedure.
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Affiliation(s)
- Georgios Kosmadakis
- Centre de néphrologie de Montargis, Bbraun-Avitum, 658 bis, rue des Bourgoins, 45200 Amilly, France.
| | - Brahim Amara
- Centre de néphrologie de Montargis, Bbraun-Avitum, 658 bis, rue des Bourgoins, 45200 Amilly, France
| | - Ghania Costel
- Centre de néphrologie de Montargis, Bbraun-Avitum, 658 bis, rue des Bourgoins, 45200 Amilly, France
| | - Catherine Lescure
- Centre de néphrologie de Montargis, Bbraun-Avitum, 658 bis, rue des Bourgoins, 45200 Amilly, France
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11
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Pinto R, Sousa C, Salgueiro A, Fernandes I. Arteriovenous fistula cannulation in hemodialysis: A vascular access clinical practice guidelines narrative review. J Vasc Access 2021; 23:825-831. [PMID: 33926285 DOI: 10.1177/11297298211006972] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The cannulation of an arteriovenous fistula (AVF) by the hemodialysis (HD) nurse is challenging. Despite it being the focus of extensive research, it is still one of the majors causes of damage making it prone to failure. A considerable number of Clinical Practice Guidelines (CPGs) for the management of vascular access (VA) have been published worldwide over the past two decades. This review aimed to assess all information available in the selected CPG regarding AVF cannulation for HD providing a comprehensive analysis in order to interpret possible future cannulation approaches. A total of seven CPGs were described in a coding table separated in seven subthemes: Initiation of cannulation, preparation, technique, needle selection, surveillance, pain, and education. Our analysis outlines current CPGs for HD VA cannulation with lack of good evidence support for the majority of the recommendations, showing that, there is an urgent need for international collaboration and coordination to ensure relevant and high-quality evidence. Future CPGs must consider recommendations with better grading of evidence aiming patient-centered care and nurse decision models that can potentially represent better AVF cannulation outcomes.
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Affiliation(s)
- Rui Pinto
- Dialysis Unit, Registered Nurse-Nephrology, University Hospital Center, Coimbra, Portugal
| | | | - Anabela Salgueiro
- Nursing School Coimbra, Coimbra, Portugal.,Portuguese Vascular Access Society, Coimbra, Portugal
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12
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Eves J, Cai P, Latham R, Leung C, Carradice D, Chetter I, Smith G. A randomised clinical trial of ultrasound guided cannulation of difficult fistulae for dialysis access. J Vasc Access 2020; 22:635-641. [PMID: 32883164 DOI: 10.1177/1129729820954725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Arteriovenous fistulae (AVF) are preferred for dialysis access but require accurate cannulation for effective dialysis. Evidence supports improvements in cannulation and complication rates using ultrasound guidance (USG) in cannulating other sites. This mixed methods, randomised controlled trial aimed to assess effects of USG during AVF cannulation. METHODS Participants with difficult to cannulate AVF had each cannulation event randomised to USG or standard technique (no USG). The primary outcome was the incidence and number of additional needle passes. Secondary outcomes included: the incidence and number of additional skin punctures; time to achieve two needle cannulation; pain associated with cannulation; local complications. Qualitative outcomes were assessed using patient and staff questionnaires. RESULTS Thirty-two participants had 346 cannulation events randomised (170 to USG and 176 to standard cannulation). USG resulted in a significant reduction in additional needle passes (72 vs 99 p = 0.007) and additional skin punctures (10 vs 25 p = 0.016.) but prolonged time to cannulation (p > 0.001). There was no difference in pain score (p = 0.705) or complications between groups. Questionnaires demonstrated that USG cannulation is acceptable to patients and staff. CONCLUSION USG cannulation of AVF is more accurate and no more painful than non-image guided cannulation, but prolonged time to cannulation. Some of the excess time involved may be due to the trial being performed early in cannulating staff's learning curve with the USG technique. Further work to elucidate which patients gain most benefit from USG cannulation and the effect of USG on cannulation complications and AVF patency is warranted.
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Affiliation(s)
- Joshua Eves
- Academic Vascular Surgery Unit, Hull York Medial School, Hull, UK
| | - Paris Cai
- Academic Vascular Surgery Unit, Hull York Medial School, Hull, UK
| | - Ross Latham
- Academic Vascular Surgery Unit, Hull York Medial School, Hull, UK
| | - Clement Leung
- Academic Vascular Surgery Unit, Hull York Medial School, Hull, UK
| | - Daniel Carradice
- Academic Vascular Surgery Unit, Hull York Medial School, Hull, UK
| | - Ian Chetter
- Academic Vascular Surgery Unit, Hull York Medial School, Hull, UK
| | - George Smith
- Academic Vascular Surgery Unit, Hull York Medial School, Hull, UK
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13
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Liu Z, Bible J, Wells J, Vadivalagan D, Singapogu R. Examining the Effect of Haptic Factors for Vascular Palpation Skill Assessment Using an Affordable Simulator. IEEE Open J Eng Med Biol 2020; 1:228-234. [PMID: 33681817 PMCID: PMC7932134 DOI: 10.1109/ojemb.2020.3017156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Goal: Simulators that incorporate haptic feedback for clinical skills training are increasingly used in medical education. This study addresses the neglected aspect of rendering simulated feedback for vascular palpation skills training by systematically examining the effect of haptic factors on performance. Methods: A simulator-based approach to examine palpation skill is presented. Novice participants with and without minimal previous palpation training performed a palpation task on a simulator that rendered controlled vibratory feedback under various conditions. Results: Five objective metrics were employed to analyze participants’ performance that yielded key findings in quantifying palpation performance. Participants’ palpation accuracy was influenced by all three haptic factors, ranging from moderate to statistically significant. Duration, Total Path Length and Ratio of Correct Movement also demonstrated utility for quantifying performance. Conclusions: We demonstrate that our affordable simulator is capable of rendering controlled haptic feedback suitable for skills training. Further, metrics presented in this study can be used for structured palpation skills assessment and training, potentially improving healthcare delivery.
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Affiliation(s)
- Zhanhe Liu
- Department of Bioengineering, Clemson University, Clemson, SC 29634, USA
| | - Joseph Bible
- Department of Mathematical and Statistical Sciences, Clemson University, SC 29634, USA
| | - Jared Wells
- Department of Bioengineering, Clemson University, Clemson, SC 29634, USA
| | - Deepak Vadivalagan
- Department of Electrical and Computer Engineering, Clemson University, Clemson, SC 29634, USA
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14
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Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1-S164. [PMID: 32778223 DOI: 10.1053/j.ajkd.2019.12.001] [Citation(s) in RCA: 865] [Impact Index Per Article: 216.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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15
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Coventry LL, Hosking JM, Chan DT, Coral E, Lim WH, Towell-Barnard A, Twigg DE, Rickard CM. Variables associated with successful vascular access cannulation in hemodialysis patients: a prospective cohort study. BMC Nephrol 2019; 20:197. [PMID: 31151432 PMCID: PMC6544962 DOI: 10.1186/s12882-019-1373-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 05/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Successful vascular access (VA) cannulation is integral to the delivery of adequate dialysis, highlighting the importance of ensuring the viability of arteriovenous access in hemodialysis (HD) patients. Missed VA cannulation can lead to infection, infiltration, hematoma or aneurysm formation resulting in the need for access revision, central venous catheter (CVC) placement, or permanent loss of VA. Cannulation-related complications can also negatively impact on a patient's dialysis experience and quality of life. This study aimed to identify patient, VA and nurse factors associated with unsuccessful VA cannulations. METHODS A prospective cohort study was conducted in HD patients with a permanent VA from three HD units. Data on patient, VA and nurse characteristics, plus, cannulation technique were collected for each episode of cannulation. General Estimating Equation was used to fit a repeated measures logistic regression to determine the odds of cannulation success. RESULTS We collected data on 1946 episodes of cannulation (83.9% fistula) in 149 patients by 63 nurses. Cannulation included use of tourniquet (62.9%), ultrasound (4.1%) and was by rope ladder (73.8%) or area (24.7%) technique. The miscannulation rate was 4.4% (n = 85) with a third of patients (n = 47) having at least one episode of miscannulation. Extravasation (n = 17, 0.9%) and use of an existing CVC (n = 6, 0.6%) were rare. Multivariable characteristics of successful cannulation included fistula compared with graft [OR 4.38; 95%CI, 1.89-10.1]; older access [OR 1.68; 95%CI, 1.32-2.14]; absence of stent [OR 3.37; 95%CI, 1.39-8.19]; no ultrasound [OR 13.7; 95%CI, 6.52-28.6]; no tourniquet [OR 2.32; 95%CI, 1.15-4.66]; and lack of post graduate certificate in renal nursing [OR 2.27; 95%CI, 1.31-3.93]. CONCLUSION This study demonstrated a low rate of miscannulation. Further research is required on ultrasound-guided cannulation. Identifying variables associated with successful cannulation may be used to develop a VA cannulation complexity instrument that could be utilised to match to the cannulation skill of a competency-assessed nurse, thereby minimising the risk of missed cannulation and trauma.
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Affiliation(s)
- Linda L Coventry
- Centre for Nursing Research, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, 6009. .,School of Nursing & Midwifery, Edith Cowan University, 270 Joondalup Drive, Joondalup, Western Australia, 6027.
| | - Jon M Hosking
- Diaverum Toto Ora Dialysis Clinic, 10 Waddon Place, Mangere, New Zealand
| | - Doris T Chan
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, 6009
| | - Evelyn Coral
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, 6009
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, 6009
| | - Amanda Towell-Barnard
- Centre for Nursing Research, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, 6009.,School of Nursing & Midwifery, Edith Cowan University, 270 Joondalup Drive, Joondalup, Western Australia, 6027
| | - Diane E Twigg
- Centre for Nursing Research, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, 6009.,School of Nursing & Midwifery, Edith Cowan University, 270 Joondalup Drive, Joondalup, Western Australia, 6027
| | - Claire M Rickard
- Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland and School of Nursing and Midwifery, Griffith University, Nathan Campus, 170 Kessels Road, Nathan, Queensland, 4111, Australia
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16
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Affiliation(s)
- Catherine Fielding
- Professional Development Advisor–Haemodialysis, Derby Renal Unit, MDT Fellow, UK Renal Registry, and Co-Chair, British Renal Society Vascular Access Special Interest Group
| | - Helen Spooner
- Advanced Nurse Practitioner–Renal Services, New Cross Hospital, Wolverhampton
| | - Margaret Aitken
- Vascular Access Nurse Clinical Specialist, Queen Elizabeth University Hospital, Glasgow and Chair, Nurses Group, Vascular Access Society of Britain and Ireland
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17
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Murphy EA, Ross RA, Jones RG, Gandy SJ, Aristokleous N, Salsano M, Weir-McCall JR, Matthew S, Houston JG. Imaging in Vascular Access. Cardiovasc Eng Technol 2017; 8:255-72. [PMID: 28707187 DOI: 10.1007/s13239-017-0317-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 06/26/2017] [Indexed: 11/16/2022]
Abstract
This review examines four imaging modalities; ultrasound (US), digital subtraction angiography (DSA), magnetic resonance imaging (MRI) and computed tomography (CT), that have common or potential applications in vascular access (VA). The four modalities are reviewed under their primary uses, techniques, advantages and disadvantages, and future directions that are specific to VA. Currently, US is the most commonly used modality in VA because it is cheaper (relative to other modalities), accessible, non-ionising, and does not require the use of contrast agents. DSA is predominantly only performed when an intervention is indicated. MRI is limited by its cost and the time required for image acquisition that mainly confines it to the realm of research where high resolution is required. CT’s short acquisition times and high resolution make it useful as a problem-solving tool in complex cases, although accessibility can be an issue. All four imaging modalities have advantages and disadvantages that limit their use in this particular patient cohort. Current imaging in VA comprises an integrated approach with each modality providing particular uses dependent on their capabilities. MRI and CT, which currently have limited use, may have increasingly important future roles in complex cases where detailed analysis is required.
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18
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Fielding CA, Cain P, Debling P, Ross J, Drysder D, Swain A, Cole R, Noble D, Angell-Barrick N, Fluck R, Rylance P, Kumwenda M. Clinical practice recommendations for the use of buttonhole cannulation. ACTA ACUST UNITED AC 2016. [DOI: 10.12968/jokc.2016.1.4.186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Catherine A Fielding
- Chair, BRS Vascular Access Special Interest Group and Professional Development Advisor–Haemodialysis, Derby Teaching Hospitals NHS Foundation Trust
| | - Pat Cain
- Renal Vascular Access Nurse, University Hospitals Coventry and Warwickshire NHS Trust
| | - Paula Debling
- Home Haemodialysis Manager, East Kent Hospitals NHS Foundation Trust
| | - Jacqueline Ross
- Jacqueline Ross, Senior Charge Nurse, Aberdeen Royal Infirmary
| | | | - Alison Swain
- Renal Vascular Access Nurse, Royal Berkshire NHS Foundation Trust
| | | | - Deborah Noble
- Senior Sister Home Haemodialysis, Epsom and St. Helier Renal Unit (Retired)
| | - Nicki Angell-Barrick
- Haemodialysis Access Advanced Nurse Practitioner, Oxford University Hospitals NHS Foundation Trust
| | - Richard Fluck
- Consultant Nephrologist, Derby Teaching Hospitals NHS Foundation Trust
| | - Paul Rylance
- Patient Safety Lead and Consultant Nephrologist, Royal Wolverhampton NHS Trust
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