St George & Sutherland Hospitals

Transcription

1 CLINICAL BUSINESS RULE TITLE Fistula - Pre and Post Operative Management for the Creation of an AV Fistula / Graft Cross References (including NSW Health/ SESLHD policy directives) Post operative procedure/management for adult patient Clinical Business Rule SGH-TSH CLIN What it is This document aims to prepare the patient appropriately for haemodialysis access surgery and prevent postoperative complications 2. Risk Rating Medium 3. Employees it Applies to Process Nursing staff at St George and Sutherland hospital 4.1 Preoperative management Bilateral mapping of the patient s upper limbs is performed to assist in successful outcome of the AV access. All duplex ultrasounds are performed at the St George Vascular Laboratory at St George Private Hospital Patient and staff should be educated that - NO blood pressure, cannula, venipuncture or ID band on the identified access limb. A Save the Vein Tattoo needs to be placed on the preserved arm An access awareness sign is to be placed above the patient s bed on admission Outpatients undergoing AV access creation will attend Pre-Admission clinic (PAC) at least 1 week prior to surgery where the following will take place: o Pre operation routine observations o Pre operation bloods done in Pathology as per Anaethetist request form o Patient is seen by an Anaethetist o Details of operation are entered into Surginet by PAC team o Nasal swab for MROs and results followed up by PAC and or Vascular team o o Patient given Triclosan wash with instructions to use on day of surgery Instructions relating to the ceasing of warfarin or other anticoagulants prior to surgery are given to the patient in consultation with both the Vascular and Renal teams If the patient is to have dialysis prior to surgery, half the normal strength of heparin is to be used for the session. If the patient routinely receives Fragmin, use 500 units of heparin for the loading and infusion dose. Cease heparin 1 hour prior to completion of dialysis The patient should be left 0.5kg above their IBW to help prevent postoperative hypotension If dialysis session falls on the day before surgery, perform routine dialysis as per patient s care plan Please note: If bloods need to be taken while the patient is on haemodialysis due to the patient having poor venous access, the patient is to present the pathology form obtained from the preadmission clinic. This ensures the relevant bloods can be organised under the correct Vascular Surgeon Approved by: : Page 1 of 5

2 4.2 Intraoperative IV antibiotic as per vascular surgeon is administered 4.3 Postoperative management The patients arm is to be kept warm, extended and elevated on a pillow for 24 hours or until the swelling subsides Monitor patency by assessing for a palpable thrill or an audible bruit hourly for 24 hours. If the thrill or bruit diminishes, assess BP and reduce UFR if the patient is on haemodialysis. If these signs are absent, remove the dressing and reassess for a thrill or bruit. If the access is not patent inform the Vascular team or Renal Vascular Access CNC immediately Limb circulatory observations are performed hourly for 24 hours to detect for signs of steal syndrome. Observe for any ipsilateral pallor, cyanosis, coldness, numbness or pain in the access limb and assess distal pulses Routine observations are monitored as per the CIBR Post operative/procedure management of an adult. Medical staff are to be notified if systolic BP is <100 mmhg. The patient may require IV fluid therapy on review by medical staff Assess and monitor access site and harvest site if saphenous vein used for bleeding and signs of haematoma prior to commencing dialysis then check hourly If bleeding is minimal, use low dose heparin during dialysis for access surgery <24 hours. Observe access site hourly for bleeding. If a haematoma arises or bleeding increases, stop heparin immediately and inform the Vascular team If bleeding is moderate or a saphenous vein was harvested <48 hours, perform a heparin free dialysis If access surgery >24 hours, bleeding is minimal, and there are no signs of a haematoma formation, routine heparin can be used 4.3 Ongoing management: Change AV access dressing 48 hours post surgery if bleeding is minimal using a non adhesive dressing until the wound is dry and then can be left exposed. If bleeding continues, redress wound and check for signs of infection If the dressing becomes soiled or wet, the dressing should be changed Remove all or alternative sutures at day 7-10 post surgery (depending on assessment and post surgery instructions) The Renal Vascular Access CNC will make an appointment for one week post surgery to provide follow up and education. A post surgery appointment with the Vascular Surgeon should be made according to the post surgery orders The bruit and thrill is checked weekly by the Renal Vascular Access CNC and each session by the attending dialysis nurses 4.4 Patient education: Provide the patient with All you need to know about your fistula brochure for further education (available in multiple languages on the renal website) Educate patient on assessing the thrill and how to care for their fistula Approved by: : Page 2 of 5

3 Encourage the patient to perform fistula exercises which can help enhance vessel maturation. Squeeze a rubber ball forcefully 10 times every hour 48 hours post surgery. Note patients with AV graft do not need to do fistula exercises Avoid any heavy lifting (> 1Kg) on the access limb for at least 8 weeks to prevent haematoma formation Advise not to wear tight clothing or any jewellery on the access limb to prevent restricting blood flow to the access 5. Keywords Fistula, Haemodialysis, post operative management 6. Functional Group All nurses 7. External References Leaf, D., Macrae, H., Grant, E., Kraut, J Isometric Exercise Increases the Size of Forearm Veins in Patients with Chronic Renal Failure. The American Journal of the Medical Science Vol.325, No. 3 Ball L. K Improving Arteriovenous Fistula Cannulation Skills. Nephrology Nursing Journal Vol. 32, No.6. Kooman, J., Basci, A., Pizzarelli, F., Canaud, B., Haage, P., Fouque, D., Konner, K., Martin-Malo, A., Pedrini, L., Tattersall, J., Tordoir, J., Vennegoor, M., Wanner, C., ter Wer, P. and Vanholder, R. 2007, EBPG guideline on Vascular Access Nephrology Dialysis and Transplantation, 22 (suppl 2), pp NKFK/DOQI (2006): D/VA/va _rec2.htm 8. Consumer Advisory Group (CAG) approval of patient information brochure (or related material) NA 9. Implementation and Evaluation Plan Including education, training, clinical notes audit, knowledge evaluation audit etc Inform staff at clinical meetings. Vascular Access Nurse will evaluate patient knowledge at routine follow up in Vascular Access clinic. Regular inservice staff on care of the fistula. Education provided by Vascular Access CNC or Renal Clinical Nurse Educator. 10. Knowledge Evaluation Q1: How do you assess if a fistula/graft is patent A: Palpate the access to assess the presence of a thrill and listen for a bruit Q2: What action is required if a thrill or bruit is absent? A: Inform the Vascular team or Vascular Access CNC Q3: What written patient educational resources are available for the Approved by: : Page 3 of 5

4 11. Who is Responsible patient with a new access and where are these found? A: All you need to know about your fistula brochure found on the renal website via the intranet Renal Medicine Director of St George and Sutherland renal services and vascular services. Nursing Unit Managers, Dialysis and Satellite Units Nursing Manager Medicine St George Hospital. Approval for (Insert Clinical Business Rule Title) * N/A where appropriate *Specialty/Department Committee *Specialty/Department Committee *Nurse Manager Committee title Chairperson name/position Committee title Chairperson name/position Name/position *Medical Head of Department *Drug and Therapeutics Committee (SGH) *Drug and Therapeutics Committee (TSH) Executive Sponsor Name /position Ivor Katz Senior staff specialist Director Haemodialysis 27/6/2017 Chairperson s Name: Chairperson s Name: Name/Position Contributors to ClBR development e.g. CNC, Medical Officers (names and position title/specialty) Revision and Approval History Approved by: : Page 4 of 5

5 Revision number Author (Position) Revision due General Manager s Ratification Name Name Approved by: : Page 5 of 5