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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!!. - PowerPoint PPT Presentation
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HEED THE HERALD BLEED: An Ominous Warning for Potential Vascular Access Rupture
Prepared by
Pauline Byrne CNSVascular Access CoordinatorRenal Centre, Wollongong, ISHLD
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 training¾ as part of a package of resources aimed at staff, patients and carers.
Remember:Heed the Herald Bleed! ......ACT! ........Save a life!
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.
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.
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.
How Can We Identify Access at Risk ?
Look- Visual Inspection
Feel-Palpate Thrill and Pulse
Listen- Character of Bruit
Observe- Access re Pressure Trends duringHaemodialysis Treatment.
VISUAL INSPECTION:
Examine Skin Integrity - Is skin thinning over access sites? Is infection present? Is Infection present with sudden appearance aneurysmal dilatation?
VISUAL INSPECTION:
Examine Skin Integrity Presence of Scabs/Blebs Exposed e PTFE Graft
Degraded PTFE graft: ‘One-site-itis”
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?
VISUAL INSPECTION:
• Development or increase in size of Aneurysmal/Pseudoaneurysmal Dilatations ?
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
Why You should not cannulate into Aneurysms & Pseudoaneurysms........
Aneurysms Pseudoaneurysms
There is no vessel nor graft in dilated wall- only skin + subcutaneous tissue.
Aneurysms as they enlargecompromise the overlyingskin of the fistula, and for those patients where skin layer is thin and prone to infection, is a sign of impending perforation.
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.
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
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.
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:
1. Do not cannulate:- Renal Registrar/Vascular Registrar review
2. If infection- septic screen / IV Antibiotics
3. Exposed e PTFE-treat as infection
4. Admission
5. Formal Duplex study of access
6. Vascular Revision if clinically required
CASE STUDY : MRS Q
Mrs. Q- 68 yrs old, ESRD-secondary to Wegeners Granulomatosis
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
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
POSTER:
“Heed the
Herald Bleed”
What Can Your Unit Achieve?
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.
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
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.
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