formation nursing epicura hornu
TRANSCRIPT
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ACCES VASCULAIRE DIALYSE LA FISTULE ARTERIO VEINEUSE
Formation nursing EPICURA HORNU
Dr Guillen A MA . Med Int Nephrologie
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Introduction
Chronic Hemodialysis Using Venipuncture and a Surgically Created Arteriovenous FistulaMichael J. Brescia,
M.D.†, James E. Cimino, M.D.‡, Kenneth Appel, M.D.§, and Baruch J. Hurwich, M.D.
N Engl J Med 1966
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Fistule et survie
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Bénéfice de la fistule AV
• Probabilité meilleur KT/V.
• Diminution d’Infection.
• Pathologie veineuse périphérique > centrale.
• Diminution anticoagulation
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HBPM/poids
0,76
0,78
0,80
0,82
0,84
0,86
0,88
0,90
0,92
0,94
0,96
KT JUGULAIRE FAV
HBPM/poids
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CONFECTION FISTULE AV
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Confection FAV
• Pré opératoire
• Intervention
• Postopératoire
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Confection FAV préopératoire
INFO DIALYSE
• Explication avantage FAV > KT
PRE OP FAV
• Antécédents MC - Médication
• Interrogatoire. (Phlébite, ponction habituelle, traumatisme, ...).
• Diathèse thrombogène.
• Diathèse hémorragique.
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Examen clinique Artère
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Examen Clinique: Artère
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Examen Clinique: Veine
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HISTOLOGIE VEINE ARTERE
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Prédiction de Succes/EChec
Accès fonctionnels
(%)
Diamètre veine < 2,1 mm
7/24 (29,2%)
Diamètre veine > 2,1 mm
15/31 (48,4%)
Céphalique
> 2,5 mm
Congrès annuel de la Société Québécoise de néphrologie 28 avril 2006
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Prédiction de Succes/EChec
Le diamètre interne veine/artère associé au succès de la FAV varie de 1,5 à 2,0 mm selon les études
Cependant, l’une de ces études remettait en doute l’utilité du Doppler pré-FAV
Seul le diamètre minimal moyen de la veine céphalique (2,51mm) était associé de façon significative au fonctionnement de la FAV
Seulement 27,3% des FAV radio-céphaliques natives étaient fonctionnelles à 6 mois (URR de 65%)
Congrès annuel de la Société Québécoise de néphrologie 28 avril 2006
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Préop médico-chirugical
Avoid
Recent infection
propreté
hydratation
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Chirurgie
Critère étudié. -Taille anastomose -Courbure termino latérale -Type d’incision
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Post opératoire immédiat.
• Vérifier intensité du thrill.
• Eviter Saignement (source d’hématome et compression).
• Eviter les hypotensions. (Chute de débit et risque de thrombose.
• Surveillance Infectieuse
• Education patient – Information Patient
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PREMIERE PONCTION
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Première ponction
• Quand ? – Développement clinique adéquat. – Evaluation echodoppler préalable Diamètre > 4 – 6 mm
selon la profondeur, profondeur < 5 mm, 2 segments de 4 cm , débit > 300ml/min
• Comment ? – Button all ou variation anatomique
• Quel Débit ?: – Selon Diamètre – Selon PA PV
• Objectif: long terme.
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Première ponction
CARTOGRAPHIE
EXAMEN CLINIQUE
EXMEN ECHOGRAPHIQUE
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Première ponction
• «
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BON CRITERE ECHOGRAPHIQUE
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MAUVAIS CRITERE ECHOGRAPHIQUE
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Complications
ARTERIELLES VEINEUSES
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Complications Artérielles
• Pathologie de Bas débit:
– Diminution du débit de la FAV.
– Majoration de la recirculation.
– Thrombose de FAV.
• Pathologie de Haut débit
– Vol sanguin. (F.Risque +++ Diabète).
– Décompensation cardiaque à haut débit.
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VOL ARTERIELLE
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BILAN
Diagnostic
ECHOGRAPHIE
FERMETURE
PTA
Artère ARTERIOGRAPHIE
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Complication veineuse
• Sténose
• Thrombose
• Dissection
• Hyperplasie
• Hémorragie
• Septicémie
• Divers
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Complication Veineuse - Sténose
• Sténose post anastomotique distale – Chute de débit, chute de PA – Récirculation – Collapsus de la FAV
• Sténose non post anastomotique – Majoration de PV si après aiguille veineuse – Recirculation – Absence de Collapsus
• Sténose Centrale – Turgescence de la FAV – Recirculation – Echec d’épuration (majoration K et Créat et Urée pré)
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Complication Veineuse Thrombose
• Mécanisme.
• Diagnostic
• Thrombose partielle.
• Thrombose totale.
• Traitement
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Mécanisme de Thrombose Vircshow
CAILLOT
STASE
COAG. LESION
PAROIS
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Mécanisme de Thrombose Vircshow: La stase
Lésion
Chute de TA
CAILLOT Sténose
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Mécanisme de Thrombose Vircshow
LESIONS: Blessure Par le Biseau Dissection Infection Hyperplasie HYPERCOAGULABILITE: Déshydratation. Infection. Polyglobulie (Hc 50%). Syndrome néphrotique Pharmacologique: Diminution anticoagulation Ac Tranexamique
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Thrombus partiel
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Thrombus total
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Complication veineuse Dissection
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Complication veineuse Hyperplasie
• Pathologie de la média.
– Partielle
– Complète
• Lésions endothéliale
• Stress répétée de Parois
• Traitement
– PTA
– PTA cutting ballon
– PTA cutting ballon phramaco
• Tendance à la répétition.
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Hyperplasie
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Complication veineuse Hémorragie
• LES BONS REFLEXES:
– Compression.
– Questionner l’Hémostase.
– Recherecher une sténose post point de ponction.
– Réévaluer l’éducation du patient.
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Complication veineuse Infection
• RECHERCHER SIGNE ☐CELSE.
• T° sans Foyer.
• RISQUE MAJEUR DE CHOC.
• RARE
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PREVENTIONS DES COMPICATIONS
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Prévention des complications: Surveillance
• Surveillance Clinique.
• Surveillance Biologique.
• Surveillance Hémodynamique.
• Surveillance Recirculation.
• Education du patient.
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Prévention des complications: Surveillance Clinique
Rôle du nursing. QUESTION Commentaire.
Observation
P Plate Sténose post anastomotique
D Dure Sténose Post veineuse
C collabe Toujours au dessus du cœur.
Ausculation
T Thrill
Au début de la FAV
S Souffle
Sur 20 cm.
P D C T S
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Surveillance Clinique Quand ?
• Dès que signe de dysfonction.
• Dès que difficulté de ponction ou complication de ponction.
• A la biologie Mensuelle
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Surveillance Biologique
• PRU • Trend du potassium • Trend de l’Urée/Créat Pré • Evolution dialysance • Test de recirculation
– Urée – Osme/Na
• Système informatisé.
Plus de 25000 données annuelles.
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Surveillance Hémodynamique
• Chute de QB
• Variation PV/PA
• Absence d’analyse statistique des variances interséances.
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RECIRCULATION
Le sang filtré est filtré à nouveau
STENOSE ARTERIELLE OU VEINEUSE ?
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RECIRCULATION
Le sang filtré est filtré à nouveau
STENOSE ARTERIELLE OU Chute de débit artérielle Donc chute débit cardiaque… SI Le retour veineux le permet…
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RECIRCULATION
Le sang filtré est filtré à nouveau
STENOSE VEINEUSE si le « LAC FAV » est suffisant …
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MAIS
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CIRCUIT SANGUIN
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• PATHOLOGIE DE l’ACCES VASCULAIRE.
• PATHOLOGIE de l’Hémodynamique.
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3 Moyens de Surveillance de la Recirculation
BIOLOGIE.
Moniteur
Device
Précision biologique
Easy
Pas de consommation sangine et déplacable.
Consomation sanguin Time consuming
Validation ? Limitation nombr de patient
Cout.
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Education Patient : Prévention complication
EDUCATION REACTION
Thrill Je le sent le matin
Douleur sans hématome le long de la FAV Je me présente dans le service
Saignement à domicile Je préviens l’infirmière.
Douleur nocturne Je préviens l’infirmière.
Hygiène Je lave les main avant.
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TRAITEMENT DES COMPLICATIONS
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Traitement Sténose
• Dilatation
– PTA: Angiolastie Percutanée
• + cutting ballon
• + Anti hyperplasiant
– PTA STENT: NON
• Repositionnement
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Traitement Thrombose
PTA
Bilan de succès
Contrôle vasculaire
Surveillance
Diagnostic Dialyse
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Traitement Hémorragie
Hémorragie
Compression
Chir ? Sténose ?
Hémostase
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Traitement de l’infection
• Antibiothérapie
– Toujours rechercher à identifier le germe
• Rechecher une endocardite.
• Signe de Choc discussion fermeture FAV en Urgence
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Traitement de l’hyperplasie
• Background:
– Stent Médicamenteux …
• MAIS
– Histologie veineuse
– Pas de possibilité de stent
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GESTION ACCES VASCULAIRE DIALYSE
Med.
Inf dy
Chir
Rx
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Néphrologue
Dialyse
Post - op
Pré - op
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INFIRMIERE DIALYSE
PONCTION
Hémodynamique
Demande diagnostic
Clinique
KT/V
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Infirmières Dialyses
Demande diagnostic
Médecin
Inf de référence
Chirurgien
Infirmière Dialyse
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Infirmières de référence , rôle ?
Educatif
Gestion Préop.
Diagnostic
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But Now ?
Mensuel CLINIQUE minute
QB PA PV
KT/V
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FEUILLES d’OBSERVATION
FEUILLE d’OBSERVATION
Date Event
FEUILLE de SUIVI
date KTV QBm PAm PVm recir
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Mais ….
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