IV placement in 4 week old Fistula! AAARGHHH!

[Juanay]

:angryfire

I am sooooo mad I had to vent! Have you ever heard of such a thing??. We have a new pt (6 weeks on dialysis) had a fistula and tunneled cath placed 6 weeks ago. Had a hypoglycemic episode that sent her to ER and after trying to find an access the nurses told her they would have to use her fistula. Fortunately, her son is an RN and told them they most deffinately would NOT use her fistula. The son left his mom briefly and when he returned, the ER doc had started an IV in her fistula!!! The son was livid and immediately DC'd the IV and told them to try again elsewhere! Then low and behold they WERE ABLE to start the IV in her other arm! ARRRGHH!!! The fistula is not even mature yet and this guy(idiot) has threatened her life line!

How do you handle these situations in a professional manner when you would love to choke these people?!

I apologize for my harsh words in advance, but I have seen tooo many infections, dead grafts in pt's I have grown to love as family. I know too that all of you dialysis staff have seen it too!

Juanay

[jnette, ASN, EMT-I]

Well, if... IF it's a life threatening situation, and no other means is working to establish a line, use any and everything. If not, then leave it alone !!!

Six weeks is usually good enough to start using a fistula.. (at dialysis).. should be about mature by then... the average is about six weeks.

My question is did they know which end of the fistula to access... the upper part (venous)..? If they cannulated into the lower arterial site (and how would someone not familiar with dialysis know where in a fistula to stick, right?)... then that tiny gauge needle could well have been blown right back out by the pressure of the fistula itself ! Can you see it? Needle, blood flying everywhere... :uhoh21:

I prefer them to use the fistula than mess with their cath, however.

At our ER up the road from our clinic, if we have to send them one of our pts. for an emergency, of course we leave the lines in, attach a syringe on one to cap the end, and leave saline running in the other... well, when the patient has stabilized in ER, they always call one of US to drive up there and pull the needles and hold the sites... they say they don't know how.......????

So no matter how busy we are at the time, one of us has to go up there and perform this majorly difficult task.. Grrr.

I understand the protectiveness, though. I feel the same way about my patients and I always hope when they're in the hospital for anything, that their lifeline is still intact, and they remain infection free.

[Juanay]

jnette,

Thanks for your reply.

She came in today for her tx with 99.0 temp and her arm was a little warm. The ER doc did use the upper part (venous limb) of her graft but now it has a large bruise on it! By post tx though her temp was normal.

"At our ER up the road from our clinic, if we have to send them one of our pts. for an emergency, of course we leave the lines in, attach a syringe on one to cap the end, and leave saline running in the other... well, when the patient has stabilized in ER, they always call one of US to drive up there and pull the needles and hold the sites... they say they don't know how.......????

So no matter how busy we are at the time, one of us has to go up there and perform this majorly difficult task.. Grrr."

Yeah, we had one go to ER yesterday for SVT's and was sent with needles in place. After he was stable they sent him back for him to finish his tx with needles still in his arm but he refused to finish his tx. He says he told ER staff to pull them so he could go home but they said "we can't do that here." SO... they sent him back so we could pull his needles and go home. So... :stone

Juanay

[Stitchie]

I don't blame you for being angry.

ER staff in my hospital WILL NOT access fistulas. Not even use the arm with a fistula.

If it's a matter of life or death, they get a TLC for access.

Dialysis will not come to the ER for any reason (not exactly sure about that). So we don't really cross paths with each other.

I green band my patients (do not use) so that anyone coming in for blood draws, bp's, etc does not use the fistula arm.

Sure, it limits access, but for dire emergencies a TLC is a better idea than blowing a fistula, for the reasons stated in other posts.

It's policy where I work.

[Juanay]

Well, if... IF it's a life threatening situation, and no other means is working to establish a line, use any and everything. If not, then leave it alone !!!

Six weeks is usually good enough to start using a fistula.. (at dialysis).. should be about mature by then... the average is about six weeks.

By the way, our protocol for fistulas is 3 months before 1st stick. Gortex grafts, 2 weeks. What is your protocol? In my home unit we start with 17G needles and low BFR (150) on 1st stick of either, increasing BFR q tx by50 until 500 is reached. We use 17G for 1 month, 16G for 1 month, then 15G. It's really hard to get a 500 BFR on 17G needles so they usually run a max of 350-400 on 17G.

Juanay

[jnette, ASN, EMT-I]

Well, if... IF it's a life threatening situation, and no other means is working to establish a line, use any and everything. If not, then leave it alone !!!

Six weeks is usually good enough to start using a fistula.. (at dialysis).. should be about mature by then... the average is about six weeks.

By the way, our protocol for fistulas is 3 months before 1st stick. Gortex grafts, 2 weeks. What is your protocol? In my home unit we start with 17G needles and low BFR (150) on 1st stick of either, increasing BFR q tx by50 until 500 is reached. We use 17G for 1 month, 16G for 1 month, then 15G. It's really hard to get a 500 BFR on 17G needles so they usually run a max of 350-400 on 17G.

Juanay

We start using the new fistula in 6-8 weeks per surgeon's recommendations. We, too start with 17 gauges but with a BFR of 200. We move up to a 16 gauge the following week, and the 15 gauge a week after that. We increase the BFR with each.

We have several who use 14 gauge needles as well. :)