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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com

WORLD EMERGENCY MEDICINE SOCIETIES

Rapid IJ (aka Easy Internal Jugular Cannulation)

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lunes, 19 de septiembre de 2016

Fistula complications

emDocs - September 18, 2016 - Author: Simon E - Edited by: Robertson J and Koyfman A
"Summary 
Nearly 400,000 individuals in the United States are maintained on HD therapy. With incident cases of ESRD reaching nearly 21,000 annually, and vascular access complications accounting for 16 to 25% of hospital admissions, understanding of the appropriate management of AV fistula complications is paramount for the emergency medicine physician..."
Key Pearls

  • Fistula complications = 16-25% of hospital admissions for HD patients
    • DASS => complication of operative creation of a HD fistula
      • Diagnosis based upon presentation and PE
        • Cool/painful limb + diminished or absent distal radial pulse, palpable only with compression of the dialysis access site => Vascular Consult
    • Hemorrhage
      • #1 = direct pressure
      • Gel foam, rhThrombin +/- DDAVP in consultation with a specialist are options
      • Consider protamine for heparin reversal if recently received dialysis
    • Infection
      • Common cause of morbidity = cover for Staph and Strep
      • Use US to differentiate perivascular cellulitis from local abscess, infected hematoma or infected thrombus.
        • Perivascular cellulitis => Vancomycin (+ gentamycin if gram negatives suspected)
        • Abscess, hematoma, thrombus => Antibiotics + vascular consult for possible OR
    • Fistula Stenosis
      • Patients present with extremity pain +/- chest wall edema
        • Order Doppler US
          • Abnormalities = consult vascular => PTCA
        • Fistula Thrombosis
          • Fistula has absent bruit or thrill = vascular consult => thrombectomy vs. thrombolysis
      • Fistula Aneurysm or Pseudoaneurysm
        • Patients present with extremity pain, compression neuropathy, or hemorrhage secondary to skin erosion.
          • Doppler US => vascular consult for abnormalities