AV fistula/shunt used as PIV what's this?!

[CaLLaCoDe, BSN, RN]

:devil: Here's the trouble. A fellow nurse of mine tonight received a renal patient from ER with an amioderone drip running at her AV fistula site. Now this nurse knows since we are not trained to deal with AV fisutulas, not to touch it period. MD writes an order to discontinue using AV fistula and start peripheral IV. What should this RN do?

The RN started a peripheral IV and is waiting for tomorrow when the dialysis nurse shows up to switch over IV sites.

[Hoozdo, ADN]

:devil: Here's the trouble. A fellow nurse of mine tonight received a renal patient from ER with an amioderone drip running at her AV fistula site. Now this nurse knows since we are not trained to deal with AV fisutula aths not to touch it period. Dr. writes an order to discontinue using AV fistula and start peripheral IV. What should this RN do?

The RN started a peripheral IV and is waiting for tomorrow when the dialysis nurse shows up to switch over IV sites.

Well, IMHO, that nurse should of never touched that fistula. That is the patient's lifeline. The ER should have never started the drip there. They should of got peripheral IV access and leave the fistula alone. If peripheral IV access could not be obtained, than this patient needs a central or PIC line stat.

I would never run any IV fluids through that fistula except in a code situation when no other access could be established.

[SCRN1]

I agree with Hoozdo. We are never to touch an AV fistula without a doctor's order and I don't recall ever being given on order to do it anyway.

Did this nurse get written up?

[km5v6r, EdD, RN]

Well, IMHO, that nurse should of never touched that fistula. That is the patient's lifeline. The ER should have never started the drip there. They should of got peripheral IV access and leave the fistula alone. If peripheral IV access could not be obtained, than this patient needs a central or PIC line stat.

I would never run any IV fluids through that fistula except in a code situation when no other access could be established

That said the nurse on the floor is left to deal with it. I worked as an acute dialysis nurse. Occasionally a pt at an outpt dialysis facility would become unstable and be transported to the hospital with the needles in place. I would then get a call at home to come and pull the needles. The frustrating thing was many times the pt would be in the ER while dialysis staff were still at the hospital but no one would call until after you got home. Either way it was a come in NOW situation. Nurses on the floor were not to try and pull the needles or leave it until morning. I have to get ready for work now but will go into the risk later if you wish.

[lashes]

If the ER doc okay'd the drip to be run via the shunt and the admit doc knows, she may not have had any other choice. A PICC is necessary however, getting a STAT one placed may be difficult if there is no one to put one in ( we wouldn't get one until the next day ) . Why didn't the ER doc put in a central line? Doesnt' sound like she touched it anyways. From what I gathered, she left the lines as they were when the pt was transferred from ER. Doesn't sound like she was gonna pull anything out even though the MD ( I'm assuming the renal guy) told her to pull it and change over to the piv. I would have left the "setup" as it was and let the dialysis nurse deal with it in the am providing the MD's knew the situation. ( and charted by butt off ) He probably had crappy veins anyways and if he was critical enough to need a drip, then i'd rather have that access than running the risk of multiple piv's blowing and the pt crashing from not having the drip.

[CaLLaCoDe, BSN, RN]

Thank you for all your responses!

I wanted to clarify that the nurse on the floor did not stop the infusion running of amiodorone running through the AV fistula; however started a saline lock for hopes that the dialyisis nurse would address the issue in the morning.

[suzanne4, RN]

My first question would be : Who cannulated that AV fistula in the first place? If not a code situation, just should not have been done. And it needs to be written up. If something would have happened to that shunt, and then the patient needed to go back to the OR? Who would take responsiblity for that? And who gave the order to cannulate it?

If the floor nurses could place a saline lock, then access did not seem like an issue in the first place.

[nuangel1, BSN, RN]

My first question would be : Who cannulated that AV fistula in the first place? If not a code situation, just should not have been done. And it needs to be written up. If something would have happened to that shunt, and then the patient needed to go back to the OR? Who would take responsiblity for that? And who gave the order to cannulate it?

If the floor nurses could place a saline lock, then access did not seem like an issue in the first place.

used to be a dialysis nurse that shunt should never have been touched .and suzanne you echoed my thoughts as well.who cannulated it to start?i would deffinately write it up.

[km5v6r, EdD, RN]

If the ER doc okay'd the drip to be run via the shunt and the admit doc knows, she may not have had any other choice

It is not the call of the ER doc or the primary doc. They have absolutely no say in this matter. It is the call of the Nephrologist alone. I have done inpt dialysis for 3 different companies in multiple facilities and no where has anyone other then the Nephrologist determine what happened with any kind of dialysis access including catheters. If the Nephrologist orders a different IV access it needs to be established and the gtt removed from the dialysis access NOW. It also means the dialysis nurse comes in NOW; even in the middle of the night; to remove the needle and protect the access. Outside of a code situation IV access is never established in a dialysis extremity let alone the access it's self. Post code and the pt survived that access is removed from the dialysis extremity ASAP. Not only are the nonNephrology docs who OKayed this situation liable but the nurse who accessed the AV graft and the nurses who cared for the pt up to the removal of the needle are liable if anything happens to that access. This is a NEVER DO situation.

[Mulan]

I would think that there would be a dialysis nurse on call that could come in and deal with it then, not in the morning.

Did the nurse consult the house supervisor about the situation?

[CaLLaCoDe, BSN, RN]

I would think that there would be a dialysis nurse on call that could come in and deal with it then, not in the morning.

Did the nurse consult the house supervisor about the situation?

Yes, I do believe the nursing supervisor was contacted regarding this serious situation....furthermore, the patient was dropped off during change of shift 0700 and follow up with the history down in ER proved futile...new people working the night shift (scant bedside reports given by days) and not really accountable to the case LOL...

Thanks for all the contributers to this thread ;+))

PS. since I was working with my Stepdown/Tele patients and it was difficult to follow all the details and OH did I ever want to go home after working three nights straight TKO. ie: totally knocked out...LOL