0' 1**#&2' 3%&0%4' .%4%' · hr of death *dopps 1+2, 1996-2004;...

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Source: Twardowski

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H PÚBLICO H PRIVADO

UTILIZACIÓN DE LA TÉCNICA SEGÚN EL TIPO DE HOSPITAL

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''''•  Una vez valorada la FAVI y elegido el punto

de punción, se deberán elegir el ángulo y la profundidad de penetración de la aguja (deberemos recordar ambas características ya que deberán repetirse en posteriores canulaciones).

•  Las primeras punciones se realizan con agujas biseladas, después de unas dos semanas de sesiones de HD (siempre a criterio del profesional), se comenzará a u t i l i z a r l a s a g u j a s r o m a s o borde romo.

Descripción de la Técnica del ojal

18

OJALES

Puntos “fijos”: Puncionar los mismos puntos con el mismo ángulo y profundidad

Roma

Standard

• Se forma tejido cicatricial y túnel

• Permite el uso de agujas romas

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Retiramos la aguja de HD una vez finalizada la sesión desinfectamos con clorexidina y procedemos a la colocación del tapón

21

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Tapón para la formación del túnel

Dispositivo Para inserción Del tapón

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Dispositivo que acompaña a los tapones y que permite su colocación de forma fácil y aséptica.

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29

Guias de su utilización del NHS Documentarse primero. Aprender de las experiencias de otros. Formación de personal. Implicar a los pacientes. Conocer los riesgos y minimizarlos.

•  ?#*24-%4'["#'+2'#&9%',+-,*%-%'.%4%'92-2&'02&'.%*,#+9#&:'

•  (#+#4'#0'6%9#4,%0'+#*#&%4,2:'

30

Recordar que no esta indicada para todos los pacientes. Tener el material necesario.

Guías Canadienses: • Un solo canulador hasta que el túnel esta realizado. • Estrictas medidas de higiene antes y después de retirar la costra de la anterior punción. • Humedecer la zona de punción para retirar la costra. • Primeras punciones con agujas biseladas y después con roma. • No para injertos. '

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Original Investigation

Effect of Buttonhole Cannulation With a Polycarbonate Peg onIn-Center Hemodialysis Fistula Outcomes: A Randomized

Controlled Trial

Emma Vaux, MD, PhD,1 Jennie King, RN, BSc(Hons),1 Swee Lloyd, RN,1

Jane Moore, RN,1 Leo Bailey, RN,1 Isabel Reading, MSc, PhD,2 andRamesh Naik, MD1

Background: Quality improvement strategies to increase and maintain the numbers of arteriovenousfistulas (AVFs) are a critical drive in enhancing the quality of care of patients receiving treatment withhemodialysis. How the AVF is needled is an important consideration in AVF survival; the ideal cannulationtechnique has not been established to date.

Study Design: Prospective randomized single-center trial.Setting & Participants: Patients on maintenance hemodialysis therapy (N ! 140).Intervention: A 1-year intervention of buttonhole (constant site) or usual-practice (different site) cannulation.Outcomes: Primary study outcome was AVF survival over 1 year, in which AVF failure was defined as an

AVF no longer used for hemodialysis (also referred to as assisted patency). Secondary outcomes includedprimary patency, number of access interventions, bleeding time, infection rate, cannulation time and pain, andaneurysm formation.

Results: Demographic data were similar for both groups. The primary outcome measure of AVF survival at 1year was statistically significantly increased in the buttonhole group (100% vs 86% with usual practice; P !0.005, log-rank test). In the buttonhole group, there were fewer interventions (19% vs 39% in usual practice)and less existing aneurysm enlargement (23% vs 67% in usual practice). There were no bacteremia events inthe buttonhole group and 2 in the usual-practice group (0.09/1,000 AVF days). There were no significantdifferences in bleeding times and lignocaine use between the 2 groups.

Limitations: A single-center study, lack of blinding.Conclusions: In this study, AVF survival was significantly greater when using buttonhole cannulation. The

buttonhole technique significantly decreased the need for access interventions and reduced existing aneurysmenlargement. Concerns of increased infection rates or prolonged bleeding times with the buttonhole techniquewere not seen in this study. The buttonhole technique should be considered the cannulation technique ofchoice for AVFs.Am J Kidney Dis. xx(x):xxx. © 2013 by the National Kidney Foundation, Inc.

INDEX WORDS: Buttonhole; cannulation; arteriovenous fistula; survival.

Creating and maintaining vascular access has beendescribed as the Achilles’ heel of hemodialysis

(HD), exacerbated by the increasing numbers andadvanced age of new patients with associated comor-bid conditions, such as diabetes mellitus and periph-eral vascular disease.1 The arteriovenous fistula (AVF)is the preferred option for vascular access for theprovision of maintenance HD treatment. Clinical opin-ion about the generally accepted method for accesspuncture is divided.2 There are 3 recognized optionsfor cannulation of an AVF3; the rope ladder pattern,the area puncture (or area dilatation) technique, andthe buttonhole technique.

The original recommendation that puncture sites bechanged for each dialysis session was made in 1966.4

This was thought to provide good healing of thepuncture wound and prevent problems such as hema-toma, stenosis, infection, and pseudoaneurysm.4 Basedon this principle, the most common practice in mostdialysis units has been to use a combination of ropeladder and area puncture techniques together in the

same patient at different times and are referred tohere, collectively, as usual-practice (different site,rotating) cannulation. However, with the rope laddermethod, a fistula with long segments appropriate forcannulation is required, and the area puncture methodweakens the fistula wall and leads to the developmentof (pseudo) aneurysms and strictures.3

From the 1Renal Unit, Royal Berkshire NHS Foundation Trust,Reading; and 2NIHR Research Design Service South Central,University of Southampton, Southampton General Hospital, South-ampton, United Kingdom.

Received May 26, 2012. Accepted in revised form January 8,2013.

Trial registration: www.isrctn.org; study number: 27841616.Address correspondence to Emma Vaux, MD, PhD, Renal Unit,

Royal Berkshire NHS Foundation Trust, Reading, United KingdomRG1 5AN. E-mail: [email protected]

© 2013 by the National Kidney Foundation, Inc.0272-6386/$36.00http://dx.doi.org/10.1053/j.ajkd.2013.01.011

Am J Kidney Dis. 2013;xx(x):xxx 1

Original Investigation

Effect of Buttonhole Cannulation With a Polycarbonate Peg onIn-Center Hemodialysis Fistula Outcomes: A Randomized

Controlled Trial

Emma Vaux, MD, PhD,1 Jennie King, RN, BSc(Hons),1 Swee Lloyd, RN,1

Jane Moore, RN,1 Leo Bailey, RN,1 Isabel Reading, MSc, PhD,2 andRamesh Naik, MD1

Background: Quality improvement strategies to increase and maintain the numbers of arteriovenousfistulas (AVFs) are a critical drive in enhancing the quality of care of patients receiving treatment withhemodialysis. How the AVF is needled is an important consideration in AVF survival; the ideal cannulationtechnique has not been established to date.

Study Design: Prospective randomized single-center trial.Setting & Participants: Patients on maintenance hemodialysis therapy (N ! 140).Intervention: A 1-year intervention of buttonhole (constant site) or usual-practice (different site) cannulation.Outcomes: Primary study outcome was AVF survival over 1 year, in which AVF failure was defined as an

AVF no longer used for hemodialysis (also referred to as assisted patency). Secondary outcomes includedprimary patency, number of access interventions, bleeding time, infection rate, cannulation time and pain, andaneurysm formation.

Results: Demographic data were similar for both groups. The primary outcome measure of AVF survival at 1year was statistically significantly increased in the buttonhole group (100% vs 86% with usual practice; P !0.005, log-rank test). In the buttonhole group, there were fewer interventions (19% vs 39% in usual practice)and less existing aneurysm enlargement (23% vs 67% in usual practice). There were no bacteremia events inthe buttonhole group and 2 in the usual-practice group (0.09/1,000 AVF days). There were no significantdifferences in bleeding times and lignocaine use between the 2 groups.

Limitations: A single-center study, lack of blinding.Conclusions: In this study, AVF survival was significantly greater when using buttonhole cannulation. The

buttonhole technique significantly decreased the need for access interventions and reduced existing aneurysmenlargement. Concerns of increased infection rates or prolonged bleeding times with the buttonhole techniquewere not seen in this study. The buttonhole technique should be considered the cannulation technique ofchoice for AVFs.Am J Kidney Dis. xx(x):xxx. © 2013 by the National Kidney Foundation, Inc.

INDEX WORDS: Buttonhole; cannulation; arteriovenous fistula; survival.

Creating and maintaining vascular access has beendescribed as the Achilles’ heel of hemodialysis

(HD), exacerbated by the increasing numbers andadvanced age of new patients with associated comor-bid conditions, such as diabetes mellitus and periph-eral vascular disease.1 The arteriovenous fistula (AVF)is the preferred option for vascular access for theprovision of maintenance HD treatment. Clinical opin-ion about the generally accepted method for accesspuncture is divided.2 There are 3 recognized optionsfor cannulation of an AVF3; the rope ladder pattern,the area puncture (or area dilatation) technique, andthe buttonhole technique.

The original recommendation that puncture sites bechanged for each dialysis session was made in 1966.4

This was thought to provide good healing of thepuncture wound and prevent problems such as hema-toma, stenosis, infection, and pseudoaneurysm.4 Basedon this principle, the most common practice in mostdialysis units has been to use a combination of ropeladder and area puncture techniques together in the

same patient at different times and are referred tohere, collectively, as usual-practice (different site,rotating) cannulation. However, with the rope laddermethod, a fistula with long segments appropriate forcannulation is required, and the area puncture methodweakens the fistula wall and leads to the developmentof (pseudo) aneurysms and strictures.3

From the 1Renal Unit, Royal Berkshire NHS Foundation Trust,Reading; and 2NIHR Research Design Service South Central,University of Southampton, Southampton General Hospital, South-ampton, United Kingdom.

Received May 26, 2012. Accepted in revised form January 8,2013.

Trial registration: www.isrctn.org; study number: 27841616.Address correspondence to Emma Vaux, MD, PhD, Renal Unit,

Royal Berkshire NHS Foundation Trust, Reading, United KingdomRG1 5AN. E-mail: [email protected]

© 2013 by the National Kidney Foundation, Inc.0272-6386/$36.00http://dx.doi.org/10.1053/j.ajkd.2013.01.011

Am J Kidney Dis. 2013;xx(x):xxx 1

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!"#$%&'()*/42-62/'%R'(,#6.2'-#'D%002'-#'0%'F13Q'!"#$%&'()*#"6$-('42)R'Q-#+AW*%*,/+'-#'4,#&>2'-#'*26.0,*%*,2+#&''KlL'.%*,#+9#&'.4#$%0#+9#&'#',+*,-#+9#&'K'%J2'&#>",6,#+92'!'-()=2>'62T-*6"44'('*8#)O4"#*#"%%'()#<*4"'%2>'('*/)4*"%*]"-&4)*("*B#&'(Y#.6'*3P(26'*("*%'*C-2D"4#2('(*("*

eZA)4('?#*0"9%6,#+92'!2$,#6C4#'NLLi^'W+'-#0'#&9"-,2'NLKL'

*'

Objetivo: Determinar la mejor tecnica de punción: Puntos diferentes (practica normal) versus puntos fijos (ojal, BH)

B<8Gq?1FQ1'

No significant difference p=0.6

Puntos Diferentes (Practica habitual)

Puntos “fijos” (ojal)

NUMERO 70 70 FAVI Nueva 25 26 FAVI Previa 45 44

HOMBRES* 44 47 MUJERES* 26 23 DIABETEICOS 18 15

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B<8Gq?1FQ1^*(Q;G'B<'F13Q' Puntos Diferentes

(Practica habitual) Puntos “fijos” (ojal)

FAVI Brazo

derecho 19 18

FAVI Brazo izquierdo

51 52

Brachiocefalica 30 31 Radiocefalica 40 39

No significant difference


!BGCl`0@eG*L*0ve*Puntos Diferentes


Aceptaron pero no

iniciaron 1 12

Cambio de técnica 0 14

Fallo FAVI 9 0 Exitus 5 6 Transplantados 3 2 Finalizaron 52 36


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4%+-26,E%-2&'eF'%**N'94%&.0%+9%-2&'K'4#A4%42+'#0'*2+&#+A6,#+92'.%4%'#0'2T%0'S'F13Q'["#'+2'6%-"42'K'0%'#+D#46#4%'-#'`B'-#*,-,/'["#'.#46%+#*,#4%'#+'#0'>4".2'-#'

.4%*A*%'5%C,9"%0'K'F13Q'0,>%-%'%+9#&'-#',+,*,%4'#0'#&9"-,2'.24'b42C2'&#$#42c'N'F13Q'9426C2&%-%'%+9#&'-#',+,*,%4'#0'#&9"-,2'


!BGCl`0@eG*L*0ve*Puntos Diferentes


Aceptaron pero no

iniciaron 1 12

Cambio de técnica 0 14

Fallo FAVI 9 0 Exitus 5 6 Transplantados 3 2 Finalizaron 52 36


**7w:E:LX'''''''?!*:ELsV'''''hSu'pQ''L:Llh'=L:iKL'''

*

Resultado principal: tiempo de fallo de la FAVI

0.75

1.00

0 100 200 300 400analysis time

trt = 0 trt = 1

Kaplan-Meier survival estimates

BH

NORMAL

Practica normal 69 52 Ojal 58 36

*Bb"6&*)A*a$S)-M)%"*]'--$%'.)-*u2&M*'*7)%R6'4O)-'&"*7"+*)-*d-W]"-&"4*?"=)(2'%R#2#*j2#&$%'*e$&6)="#^*0*!'-()=2>"(*])-&4)%%"(*`42'%*<66%'3%"Y^^'M#++,#'U,+>^'#9'%0:'0JK@*320"6#'sN^'Q&&"#'K'^'kK=kk^'M"0_'NLKO''

L*'x)*("*A$-62)-'=2"-&)*

Ojal 74% Practica Normal 49%

7*w*:E:LVs******!!*:EXos''''hSu'pQ'L:NOs'=L:kkk''

0.25

0.50

0.75

1.00

0 100 200 300 400analysis time

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Kaplan-Meier survival estimates

BH

NORMAL

d\`B!1B\]de\BG*

7*w*:E::L'''''';#%4&2+'*5,NgSj'w''NK:iiLh''

Number of Fistulaplasties

05

10152025

Normal BH

n=27 n=11

Intervenciones FISTULAPLASTY FOR STENOSIS DE-CLOT

NORMAL 25 2 OJAL 10 1

Numero de intervenciones


`'#'*("*d-A"662)-"#*

PRACTICANORMAL

OJAL

Bacteraemia 2

(MSSA) 0.09/100

0 AVF days

0

Infección orificio

0 2 (cultivo negativo)

j01d*O'6&"4'"=2'*-  1!*#EFFF#GBHI#7-$0'

t  NLLS 'L:Ki't  NLLs' 'L:NS't  9::V** *:E::*t  9::s *:E:V*t  9::; *:E:L*t  9:L: *:*

*j01d*)42U62)*-  1!*#EFFF##GBHI#7-$0#

t  NLLS 'L:S't  NLLs' 'L:lO't  9::V *:EL;*t  9::s *:E9L*t  9::; *:E:y*t  9:L: *:E:V*

''

TDC Bacteraemia – acumulativo incidencia Per 1000 catéter día

–  2005 1.8 –  2006 1.7 –  2007 0.7 –  2008 0.52 –  2009 0.29 –  2010 0.35

TDC orificio salida Per 1000 catéter día

–  2005 1.0 –  2006 1.5 –  2007 0.63 –  2008 0.26 –  2009 0.54 –  2010 0.45



j)4='62T-*("*-$"D)#*'-"$42#='#*

Ojal Normal Nuevos aneurismas

2 9 11

Sin nuevos aneuri-smas

43 45 88

45 54 99

99/127 Sin aneurismas previos

p=0.063

28/127 aneurismas previos p=0.039

0$="-&)*("*'-"$42#='#*"Z2#&"-&"#*

Ojal Normal

Mas grande 3 10 13

Igual tamaño

6 4 10

Más pequeño

1 1 2

No conocido 3 0 3

13 15 28

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Nuestra Experiencia: •  Dos años utilización:

2009-2011 •  Hemodiálisis

domiciliaria: –  10 pacientes

entrenados, todos en auto punción, en todos fue posible la creación del túnel. Un episodio de enrojecimiento en zona de punción.

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Nuestra Experiencia:

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Hemodiálisis “frecuente: 1 embarazada.

Nuestra Experiencia

•  Rescate “brazos difíciles”. –  FAV

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0' 1**#&2' 3%&0%4' .%4%' · hr of death *dopps 1+2, 1996-2004;...