A well-functioning arteriovenous fistula offers the most adequate haemodialytic treatment. Complications due to vascular access represent nearly 30% of inpatient hospitalisation (normally due to thrombosis) and are an important cause of morbidity and mortality in such patients.Daily on haemodialysis units, nurses have to make specific interventions and determine specific outcomes for each patient and situation. The puncture of an arteriovenous fistula is one of these situations due to the fact that the correct puncture is a fundamental factor for a good haemodialysis session.Often punctures are accompanied by haemorrhages and frequent loss of blood, with side effects, which we all know, especially a drop in haemoglobin. Knowing how important the blood loss in regular haemodialysis patients is we thought it important to study the puncture technique.We carried out a study of seventeen patients with end-stage renal disease on a regular programme of haemodialysis three times a week, four hours per session and bearers of an arteriovenous fistula as vascular access, for a period of six months. Our goal was to determine which puncture technique would minimise the occurrence of haemorrhages -whether to puncture with the bevel upward or the bevel downward.In our study we punctured all seventeen patients for a period of three months (374 punctures) with the bevel upward and the other three months (374 punctures) the same patients with the bevel downward. 16G needles were used in all punctures.Of the 748 punctures made there was only 27 (3.6%) haemorrhages. In the punctures made with the bevel upward 26 (6.9 %) haemorrhages occurred; of the punctures made with the bevel downward 1 (0.26%) haemorrhage occurred.We can conclude that the bevel downward puncture reduces substantially the occurrence of haemorrhage, minimising blood loss during treatment and also provokes a smaller laceration of the skin. However there are some difficulties with this procedure including greater resistance of the skin to the penetration of the needle. Another difficulty found was in the presence of large veins the position of the needle hindered the maintenance of the blood flow.Despite the difficulties found we conclude that puncture of arteriovenous fistulae with the bevel downward increases the quality of treatment by preventing blood loss during the haemodialysis session. BIBLIOGRAPHY 1. Dauguirdas JT, Ing TS. Handbook of dialysis.
Summary Continuous Renal Replacement Therapy (CRRT) is frequently used in patients admitted to intensive care units with multiple organ failure and acute renal failure. These patients are prone to developing hypotension making it very difficult to use conventional haemodialysis for their treatment. When compared to conventional haemodialysis CRRT has obvious clinical advantages. These advantages are mostly due to slow volume and uraemic toxin removal leading to better haemodynamic tolerability for such patients. In our unit during the year 2000, 58 patients were submitted to CRRT: 14 of the patients underwent treatment with continuous veno‐venous haemofiltration and 44 were submitted to continuous veno‐venous haemodiafiltration. The mean patient age was 61.7 years (range: 20–87), 36 male and 22 females. Twenty patients (43.1%) had sepsis, 18 (31%) were post open‐heart surgery, 7 (12%) had multiple organ failure, 4 (6.9%) were polytraumatised, 3 (5.2%) were post neurosurgery and 1 (1.8%) was a liver transplant patient. Despite the grave prognosis of these patients, 22 (37.8%) survived and 36 (62.2%) died. Of the patients that survived, 10 (17.2%) recovered renal function and 12 (20.6%) remained on a regular haemodialysis programme. The authors conclude that CRRT seems to be an alternative to conventional haemodialysis for the treatment of those patients with acute renal failure.
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