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Heed the Herald Bleed: An Ominous Warning for Potential Vascular Access Rupture

Heed the Herald Bleed: An Ominous Warning for Potential Vascular Access Rupture. Prepared by Pauline Byrne CNS Vascular Access Coordinator Renal Centre, Wollongong, ISHLD. Heed the Herald Bleed……… and ACT!!.

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Heed the Herald Bleed: An Ominous Warning for Potential Vascular Access Rupture

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  1. Heed the Herald Bleed: An Ominous Warning for Potential Vascular Access Rupture Prepared by Pauline Byrne CNSVascular Access CoordinatorRenal Centre, Wollongong, ISHLD

  2. Heed the Herald Bleed……… and ACT!! • Clinical Excellence Commission (CEC), 2010 RCA of fatal bleed from an AV fistula (IIMS) • Review of similar events:  identified five other deaths and nine significant incidents. • 2011: a further death as result of bleeding from an AV fistula • The CEC asked ACI for advice on prevention and education resources. • This PowerPoint was developed to assist with staff training • as part of a package of resources aimed at staff, patients and carers. • Remember:Heed the Herald Bleed! ......ACT! ........Save a life!

  3. Objectives of this Presentation : • To define a ‘Herald Bleed’ & potential outcome • To assess Access Functionality & identify ‘Vascular Access at Risk’ • Outline one centre’s ‘Acute Management Plan’ • Describe the role of stakeholders in management of access at risk • To demonstrate through a case study review: recognition and management of an access at risk of rupture.

  4. What is a : ‘Herald Bleed’ • Definition: ‘Herald’ - an indication of something that is going to happen • In relation to either an Arterio-Venous Fistula (AVF) or Arterio-Venous Graft (AVG), a herald bleed refers to either a small or large spontaneous haemorrhage. • A herald bleed may lead to potential vascular access rupture and loss of life.

  5. Introducing Mrs.Q • Mrs. Q- 68 yrs old, ESRD-secondary to Wegener’s Granulomatosis • PTFE Loop inserted Right thigh-24/09/2007 • Presented ED 2 years post-insertion –afebrile, chills, and graft red and painful. • Blood Culture/Treated IV Antibiotics • Day 7-Abscess over graft/blister like appearance, spontaneous bleed in a Satellite unit on dialysis.

  6. How Can We Identify Access at Risk ? Look- Visual Inspection Feel-Palpate Thrill and Pulse Listen- Character of Bruit Observe- Access re Pressure Trends during Haemodialysis Treatment.

  7. Visual Inspection: Examine Skin Integrity - • Is skin thinning over access sites? • Is infection present? • Is Infection present with sudden appearance aneurysmal dilatation?

  8. Visual Inspection: • Examine Skin Integrity • Presence of Scabs/Blebs • Exposed e PTFE Graft

  9. Degraded PTFE graft: ‘One-site-itis”

  10. Visual Inspection: • Is access limb oedematous? • If an upper limb access -the presence of collateral veins, and over chest may indicate central venous stenosis • Is there facial oedema same side as access?

  11. Visual Inspection: • Development or increase in size of Aneurysmal/Pseudoaneurysmal Dilatations ?

  12. Aneurysms & Pseudoaneurysms Aneurysm formation in primary fistulae can be due to– • Stenosis • cannulation technique- such as area puncture • Area puncture technique can cause: • thinning of the skin at puncture sites • Bleeding along needles • Longer bleeding time post-dialysis • Pseudoaneurysms are caused by- • degeneration of graft material combined with venous outflow stenosis • If Pseudoaneurysms have- • rapid expansion in size exceeding twice the diameter of the graft + viability of the overlying skin threatened‘ Are at risk of Rupture’  Requires Vascular Review

  13. Aneurysms Pseudoaneurysms Why You should not cannulate into Aneurysms & Pseudoaneurysms........ Aneurysms as they enlarge compromise the overlying skin of the fistula, and for those patients where skin layer is thin and prone to infection, is a sign of impending perforation. There is no vessel nor graft in dilated wall- only skin + subcutaneous tissue.

  14. Assessing Functionality:Why palpate and auscultate access? *Indicators for identifying stenosis* • Palpation • The ‘Thrill’-at the anastomosis- should be prominent and continuous, with the pulse soft and compressible. • If stenosis –thrill may only be present in systole, the pulse may be increased and have a ‘water-hammer character’ • Auscultation-The bruit should be continuous and low pitch. • If stenosis- the character of the bruit changes to a high pitch & discontinuous.

  15. Assessing Functionality:What Other Observations are Useful? • Resistance on cannulation • Can indicate stenosis + if clotting = possible impending thrombosis • Measuring Trends in Venous & Arterial Pressures. • Venous Pressure- trend upwards can indicate venous stenosis • Arterial Pressure- below -150/-250 may indicate inflow stenosis • Observe Bleeding time post-dialysis • Post-Dialysis: Prolonged bleeding may indicate proximal stenosis

  16. Diagnostic Confirmation of Access at Risk: • Formal Duplex Assessment:a non-invasive method of evaluating: arterial & venous stenoses, graft thrombosis, infection, aneurysm, pseudoaneurysm formation and arterial steal. • Access Flow Measurement: Risk of Access Failure: Fistula flow < 500 mls/min Graft < 600 mls/min. Trends and setting of individual thresholds advised.

  17. One Unit’s Action Plan If Access suspected at risk of Rupture: • Suspected infected fistulae/grafts, identified herald bleed, evident black scab or blebs, sudden onset aneurysmal dilatation, exposed e PTFE grafts: • Do not cannulate:- Renal Registrar/Vascular Registrar review • If infection- septic screen / IV Antibiotics • Exposed e PTFE-treat as infection • Admission • Formal Duplex study of access • Vascular Revision if clinically required

  18. Case Study : Mrs Q • Mrs. Q- 68 yrs old, ESRD-secondary to WegenersGranulomatosis • 24/09/2007: PTFE Loop inserted Right thigh • Presented ED 2 years post-insertion: afebrile/chills/graft red & painful. • Blood Culture/Treated IV Antibiotics • Day 7: Abscess over graft/blister like appearance; spontaneous bleed in a satellite unit on dialysis. • Vascular review: formal U/S, IV Antibiotics • 31/07/2009: ’small spurt’ • ‘Blister ruptured - small opening’ • 31/07/2009: Revision - new PTFE tunnelled, old loop excised. • Graft cultured-MRSA • IV Antibiotics: Vancomyocin x 6 weeks

  19. Ongoing Management-Targeting Education to Stakeholders • Patients & Carers:to recognise and inform medical & nursing staff of abnormalities noted with their vascular access, have knowledge of what to do in an emergency. • Nursing Staff:to recognise a vascular access at risk & report to medical staff, provide & review education to patients on a regular basis, provide patients with a ’Bleeding Emergency Kit’ • Resident Medical Officers/Medical Registrars:to recognise the normal attributes of vascular access with high blood flows, to recognise what defines a vascular access at risk, and implement treatment plan as per local policy guidelines

  20. Poster:“Heed the Herald Bleed”

  21. What Can Your Unit Achieve?

  22. In Summary This Presentation has: • Defined a herald bleed as ‘ ...spontaneous small or large haemorrhage from an AVF/AVG’ • Described: how to assess functionality of an AVF/AVG & to identify types of vascular access at-risk of rupture • Outlined both an acute management plan, and a teaching strategy for relevant stakeholders • Demonstrated through a patient case study:the detection of an access at risk with subsequent medical and surgical management.

  23. References: • Bachleda et al.,2010,’Infectious Complications of Arteriovenous e PTFE Grafts for Haemodialysis’, Biomedical Papers of the Medical Faculty of Polacky University in Olomouc,Czech Republic,pp.13-19 • Caksen et al., 2003, ‘Spontaneous Rupture of Arteriovenous Fistula in a Chronic Dialysis Patient’, The Journal of Emergency Medicine,pp.224-225 • GOOGLE IMAGES • Kapoian et al., Dialysis Access and Recirculation, Chapter 5,pp.1-14,www.kidneyatlas.org/book 5. • Mc Cann et Al.,2008,’Vascular Access Management 1:An Overview’, Journal of Renal Care,pp.77-84 • Mc Cann et Al.,2009, ‘Vascular Access Management II:AVF/AVG Cannulation Techniques and Complications’, Journal of Renal Care, pp.90-98

  24. References (cont.): • National Kidney Foundation-KDOQI –Clinical Practice Guidelines for Vascular Access Update 2000,www.kidney.org/professionals/kdoqi/guidelines • Tordoir et al.,2007 ‘European Best Practice Guidelines on Vascular Access’, Nephrology, Dialysis and Transplant Journal.pp.88-117 • Tricht et AL., 2005,’Haemodynamics and Complications Encountered with Arteriovenous Fistulas and Grafts as Vascular Access for Haemodialysis: A Review', The Annals of Biomedical Engineering pp.1142-1156 • Yan et al.,2009, ’Successful surgical treatment of a ruoture to an arteriovenous fistula aneurysm’, ‘Cardiovascular Journal of Africa’, pp.186-197.

  25. Acknowledgements: • Professor Maureen Lonergan Director Renal Services, Illawarra and Shoalhaven Area • Dr Kohlhagen, Dr Holt, Dr Greenstein, Dr Wen and Dr Zafiriou Nephrologists, Wollongong Renal Centre • Dr Huber, Dr Villalba and Dr Stanton Vascular Surgeons, Wollongong • Dialysis Staff Wollongong/Shellharbour/Shoalhaven • Mrs. Q Case Notes

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