Accessing patients, patient records, and patient databases: the "confidentiality-access maze". Part II.
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Computer Security↗
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Surgical technique. Intravenous access: obtaining large-bore access in the shocked patient.
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Catheterization, Peripheral↗
Evaluation of a polymer implanted port access device.
UNLABELLED: The implanted port vascular access system has provided many patients with safe and reliable vascular access. Its implanted design provides improved body image, reduced maintenance and a better quality of life. The Huber needle has been the standard means of accessing the implanted port system. Because of the problems associated with the Huber needle system, current standards recommend that the Huber needle be changed every 7 days. This evaluation examines the use of a polymer cannula to access the implanted port system. This polymer cannula eliminates many of the problems associated with the Huber needle and provides longer dwell times without increased complications. Seventy nine patients were accessed for a total of 1533 days with the mean dwell time being 19.4 days with no increase in complications associated with port access. OBJECTIVE: To establish implanted port access times of greater than 7 days without increased complications. DESIGN: A multicenter voluntary enrollment evaluation of a medical device. PATIENTS: Patients were offered the opportunity to participate in the evaluation if they had an implanted port and were going to be accessed for therapy for periods of 7 days or more. MEASUREMENTS: Patients were observed for adverse cutaneous reactions at the insertion site and any port access complications such as sepsis, leakage, changes in portal chamber integrity, and implant pocket integrity. RESULTS: From October 1994 through November 1995, 79 L-Cath for Ports (Luther Medical Products) polymer catheter port access devices (Illustration 1) were inserted in 54 patients. This polymer port access device was used instead of a rigid metal Huber needle for port access. The total number of access days was 1533 days with the mean duration of access being 19.4 days. Two patients experienced blood stream infections while they were accessed with the polymer port access device. These infections ensued with fever of unknown origin as the presenting symptom during neutropenic episodes after chemotherapy treatment. The port access device was removed and the port access device tip was cultured with culture results being negative. No other patients experienced complications related to the port access device. CONCLUSION: The polymer port access device provided a safe and effective means of extending port access times. This reduced the number of restarts for the patients and could extend portal septum life by exposing the portal septum to fewer accesses.
Catheters, Indwelling↗
Flow reduction in high-flow arteriovenous access using intraoperative flow monitoring.
PURPOSE: This study used intraoperative monitoring of the access flow to evaluate the results of flow reduction in the management of high-flow arteriovenous access-related symptoms of distal ischemia and cardiac insufficiency. METHODS: A retrospective study was conducted of 95 patients (78 with ischemia, 17 with cardiac failure) who underwent flow reduction between 1999 and 2005. A preoperatively measured access flow-volume rate > 800 mL/min for autogenous accesses (n = 77) and > 1200 mL/min for prosthetic accesses (n = 18) was the selection criterion for the use of a flow reduction procedure. Flow reduction was achieved using a spindle-like narrowing suture near the anastomosis and final placement of a polytetrafluoroethylene strip while a flow meter was used for intraoperatively measuring the access flow. The desired postoperative flow was 400 mL/min for autogenous and 600 mL/min for prosthetic accesses. RESULTS: The mean preoperative access flow was 1469 +/- 633 mL/min in patients with ischemia and 2084 +/- 463 mL/min in patients with cardiac failure, without significant differences between access types. The flow was reduced to 499 +/- 175 mL/min for autogenous accesses and to 676 +/- 47 mL/min for prosthetic accesses. The mean follow-up was 25 months (range, 1 to 73 months). Complete long-term relief of symptoms was observed in 86% of patients with ischemia and in 96% of patients with cardiac failure. Reconstruction significantly increased the digital-brachial index (0.41 +/- 0.12 vs 0.74 +/- 0.11; P < .05) and mean distal arterial pressure (47 +/- 17 mm Hg vs 79 +/- 21 mm Hg; P < .05) in patients with ischemia. Primary patency rates were significantly better for reconstructed autogenous accesses compared with rates of prosthetic accesses (91% +/- 4% vs 58% +/- 12% at 12 months; 81% +/- 6% vs 41% +/- 14% at 36 months; P < .001). The low patency of reconstructed prosthetic accesses is due to the high thrombosis risk of accesses that have a flow < 700 mL/min. CONCLUSIONS: Flow reduction using intraoperative access flow monitoring is an effective and durable technique allowing for the correction of distal ischemia and cardiac insufficiency in patients with a high-flow autogenous access. The desired postoperative access flow of 400 mL/min is not associated with an increased risk of thrombosis. Flow reduction of prosthetic access is as effective; however, a higher access flow than the desired 600 mL/min seems to be necessary to achieve an acceptable patency in prosthetic accesses.
Arteries↗
Prosthetic thigh arteriovenous access: outcome with SVS/AAVS reporting standards.
PURPOSE: Differences in the reporting methods of results for arteriovenous (AV) access can dramatically affect apparent outcome. To enable meaningful comparisons in the literature, the Society for Vascular Surgery and the American Association for Vascular Surgery (SVS/AAVS) recently published reporting standards for dialysis access. The purpose of the present study was to determine infection rates, patency rates, and possible predictive factors for prosthetic thigh AV access outcomes with the reporting standards of the SVS/AAVS. METHODS: A retrospective analysis was performed of all patients who underwent placement of thigh AV access by the Surgical Teaching Service at Greenville Memorial Hospital between 1989 and 2001. Outcomes were determined based on SVS/AAVS Standards for Reports Dealing with AV Accesses. The rate of revision per year of access patency was also determined; this end point more accurately reflects the true cost and morbidity associated with AV access than do patency or infection rates alone. RESULTS: One hundred twenty-five polytetrafluoroethylene thigh AV accesses were placed in 100 patients. Nine accesses were excluded from the study, six because there was no patient follow-up and 3 as a result of deaths unrelated to the access procedure and which occurred less than 30 days after access placement. There were six (4%) late access-related deaths. There were 18 (15%) early access failures, related to infection in 14 cases (12%), thrombosis in three cases (2%), and steal in one case (1%). Early failure was more common in patients with diabetes mellitus (P =.036). The primary and secondary functional patency rates were 19% and 54%, respectively, at 2 years. Infection occurred in 48 (41%) accesses. The patency and infection rates were not influenced by patient age, gender, body mass index, or diabetes mellitus. The median number of interventions per year of access patency was 1.68, and this outcome was positively correlated with body mass index (P <.001). CONCLUSIONS: Prosthetic AV access in the thigh is associated with higher morbidity compared with that reported for the upper extremity, and should be considered only if no upper extremity AV access option is available. Early access failure and the requirement for an increased number of interventions to reestablish and maintain access patency are more common in patients with diabetes mellitus and obesity. The number of interventions per year of access patency is a valuable end point when assessing the outcome of AV access procedures.
Blood Vessel Prosthesis Implantation↗
Utilization of inpatient and outpatient resources for the management of hemodialysis access complications.
Complications of hemodialysis accesses are a major cause of morbidity in chronic hemodialysis patients. Although several investigators have reported on the utilization of inpatient services for hemodialysis access complications, there is a paucity of data regarding the utilization of outpatient services and temporary accesses for these complications. In this retrospective study, we identified all access-related inpatient admissions and outpatient encounters and procedures performed in an incident cohort of hemodialysis patients. Eighty-eight patients were followed for an average of 487.4 +/- 316.9 days, for a total of 119.1 patient-years of risk. The mean age was 57.0 +/- 14.6 years, with 55% females and 65% blacks; 31% of patients had diabetes mellitus as the primary cause of end-stage renal disease. Patients were referred to our nephrology practice a median of 56 days prior to the placement of a hemodialysis access and a median of 76 days prior to the initiation of hemodialysis. At the initiation of hemodialysis, 48 native arteriovenous fistulas and 40 polytetrafluoroethylene grafts were placed. Only 28 patients (31.8%) had a permanent access placed at least 14 days before the start of hemodialysis, resulting in the placement of 93 temporary accesses during the first week of dialysis therapy. Because of access complications, 21 patients had failure of their primary access, requiring the placement of 33 additional permanent accesses, including six native arteriovenous fistulas, 23 polytetrafluoroethylene grafts, and four permacaths, or an average of 0.28 new accesses per patient-year of risk. During the study period, 45 patients (51%) had at least one access complication. To manage these access complications, 25 fistulograms (0.21 per patient-year of risk) were performed and 116 additional temporary accesses (0.97 per patient-year of risk) were placed, including 50 femoral (43.1%), 52 subclavian (44.8%), and 14 internal jugular (12.1%) catheters. A total of 2.43 inpatient days and 1.05 outpatient encounters per year of patient risk were directly attributed to admissions solely for access complications. There is significant utilization of outpatient services, temporary accesses, and fistulograms in the management of hemodialysis access complications. These services should be included whenever a review of hemodialysis access procedures or costs are undertaken.
Adult↗
Genetic analysis of Spanish melon ( Cucumis melo L.) germplasm using a standardized molecular-marker array and geographically diverse reference accessions.
Genetic relationships among 125 Spanish melon ( Cucumis melo L.) accessions from a Spanish germplasm collection were assessed using a standard molecular-marker array consisting of 34 random amplified polymorphic DNA (RAPD) markers bands (19 primers) and 72 reference accessions drawn from previous studies. The reference accession array consisted of a broad range [Japanese (19) Crete (17), African (15), and USA and Europe (US/EU, 21)] of horticultural groupings (Group Cantalupensis, Group Conomon, Group Inodorus, Group Flexuosus, and Group Chito), and of melon market classes (e.g., Charentais, U.S. Western and European Shipper types, Ogen, and Galia, Honeydew, and Casaba). Spanish melon accessions (largely Casaba, Group Inodorus) were genetically distinct from the reference accessions and other Group Inodorus melons of different origins. Most African accessions showed common genetic affinities, and grouped with the Group Chito and the Group Conomon accessions examined. Those accession groupings were distinct from all other accessions belonging to Group Cantalupensis, Flexuosus, and Inodorus accessions originating from Crete, Japan, Europe, and the U.S. Genetic diversity was highest in accessions of African origin and lowest in accessions of Spanish origin. Additional RAPD markers (49 primers, 141 bands) and 22 selected agronomic traits (quantitative and qualitative) were then used to assess the genetic diversity among Spanish accessions. While cluster analysis using fruit characteristics grouped accessions into cultivars, RAPD-based genetic-distance estimate did not provide consistent accession groupings either by cultivar or geographic origin. While the highest level of polymorphism was detected among melons originating from the central region of Spain, and in the Rochet cultivar, accessions from the Andalucía region and Green cultivars were comparatively less diverse. These results indicate that the Spanish melon accessions could be used to broaden the genetic base of local and foreign Casaba germplasm, to enhance the genetic diversity of U.S and European commercial melon germplasm, and to delineate collection strategies for acquisition of additional Spanish landraces.
Cucumis melo↗
Access related complications during percutaneous nephrolithotomy: urology versus radiology at a single academic institution.
PURPOSE: A recent survey revealed that only 11% of urologists performing percutaneous nephrolithotomy routinely obtained percutaneous access themselves. Reasons for this trend may include lack of training, comfort level and perceived need for radiological involvement. In this study we evaluated percutaneous access for percutaneous nephrolithotomy obtained by interventional radiologists or a urologist at a single academic institution, and compared access trends and complications. MATERIALS AND METHODS: Two cohorts of patients who had undergone percutaneous nephrolithotomy between 1999 and 2003 were reviewed. Percutaneous access was performed by a group of interventional radiologists (group 1) or a urologist (group 2). An access difficulty score was calculated using patient, stone and procedural variables. Primary outcome measures of percutaneous access complications such as bleeding, failure of access, pneumothorax or other organ injury were compared between groups. Secondary outcome measures of stone-free rates were also compared. RESULTS: In groups 1 and 2, 54 and 49 patients were identified with a total number of tracts of 54 and 60, respectively. Both groups had similar rates of supracostal access. Mean access difficulty scores were similar between groups. Access related complications were significantly higher in the radiology access group (15 vs 5). Stone-free rates were significantly better in the urology access group (86% vs 61%). CONCLUSIONS: Despite similar access difficulty between groups, access related complications were less and stone-free rates were improved during urologist acquired percutaneous access. Urologists instructed in percutaneous access may be able to provide improved stone-free rates during percutaneous nephrolithotomy while minimizing access related complications.
Academic Medical Centers↗
Effects of systemic hemodynamics on flow within vascular accesses used for hemodialysis.
Absolute value of access flow (QA) and change in flow (deltaQA) over time are major determinants of access patency. However, QA may change in response to variation in systemic hemodynamics among dialysis sessions. We examined the effect of mean arterial pressure (MAP), cardiac output (CO), and segmental resistances (R) on QA. Access flow and CO (L/min) were determined by Transonic ultrasound dilution. Static intra-access pressures (mm Hg) at the arterial segment (AS) and venous segment (VS) were determined with the access unoccluded. During access occlusion (O), the AS pressure was equated to arterial pressure (MAPo), whereas the VS pressure reflected venous pressure (VP). Total and segmental vascular resistances (mm Hg-min/L) were calculated as deltaP/Q. We studied 58 arteriovenous (AV) grafts and 35 autologous AV fistulae (AVF) with measurements on two or more occasions in 43 grafts and 25 AVF. MAPC differed from MAPo by >20 mm Hg in 22% of patients. AS (58 +/- 2 vs. 31 +/- 2) and VS (40 +/- 1 vs. 25 +/- 2) were greater in grafts than in AVF, whereas VP was equal. Access flow (0.91 +/- 0.03 vs. 0.91 +/- 0.05 L/min), cardiac output (5.1 +/- 0.1 vs. 5.5 +/- 0.2 L/min), and total access resistance (115 +/- 5 vs. 11 +/- 6) were equal in grafts and AVF, but non-access systemic R was lower in patients with AVF that those with grafts (26 +/- 1 vs. 30 +/- 1). AS and VS resistances were greater in AVF than grafts (87 +/- 6 vs. 54 +/- 3 and 37 +/- 3 vs. 16 +/- 3). Multivariate analysis indicated that CO and ipsilateral MAPo affected flow in both access types. In grafts, all three access resistance elements, AS, VS, and total independently influenced flow, whereas in AVF, the VS did not. Unexpectedly, the ratio of systemic to access resistance also influenced access flow. The pressure in the venous system draining the access affected access flow in AVF but not grafts. We conclude that the hemodynamics of grafts and AVF differ. Cardiac output, MAP, and the arterial segment resistance influence QA in both access types and need to be considered when evaluating QA as part of the trend analysis for detecting access dysfunction.
Aged↗
Does a ureteral access sheath facilitate ureteroscopy?
PURPOSE: Ureteral access sheaths were initially developed to facilitate difficult ureteroscopic access. However, to our knowledge no formal evaluations have been performed to assess the routine use of ureteral access sheaths. Therefore, we prospectively analyzed intraoperative time, symptomatic outcome, major complications, stone-free rate and overall costs related to the routine use of a new ureteral access sheath during standard ureteroscopic procedures. MATERIALS AND METHODS: Patients undergoing 6.5Fr semirigid or 7.5Fr flexible ureteroscopy were prospectively randomized to unaided ureteroscopy with no access sheath or ureteroscopy via a 12-14Fr ureteral access sheath. Patients who required ureteral dilatation were randomized to the ureteral access sheath used as a dilator or a standard 18Fr ureteral balloon dilator. Patients were evaluated postoperatively on days 0, 1 and 6 with a questionnaire to assess pain, irritative symptoms and complications. The stone-free rate and long-term complications were determined by excretory urography or computerized tomography at 3 months. RESULTS: Enrolled in the study were 59 consecutive patients, who underwent a total of 62 ureteroscopic procedures. Of the 47 patients (76%) who did not require ureteral dilatation 23 (49%) underwent ureteroscopy via the ureteral access sheath and 24 (51%) underwent unaided ureteroscopy. Seven of the 15 patients (28%) who required ureteral dilatation underwent access sheath dilatation, while balloon dilatation was performed in 8. There was no significant difference in postoperative symptoms, complication rate or stone-free status in the access sheath and nonaccess sheath groups in patients not requiring ureteral dilatation (p <0.05). A significant increase in postoperative symptoms was noted when the balloon was used as a dilator compared to the access sheath. Operative time and costs in all patients who underwent access sheath dilatation were less than in those in whom the access sheath was not used. In the 15 patients who required dilatation 71% of access sheath and 100% of balloon dilatations were successful. CONCLUSIONS: Routine use of a ureteral access sheath appears to facilitate semirigid and flexible ureteroscopy by decreasing operative time and costs, allowing direct visualization of ureteroscope insertion with simple ureteral re-entry and assisting renal and ureteral access with minimal associated morbidity. A ureteral access sheath should be considered for routine ureteroscopic procedures.
Adult↗
Radiation exposure and patient experience during percutaneous coronary intervention using radial and femoral artery access.
The aim of this study was to evaluate radiation dose and patient discomfort/pain in radial artery access vs femoral artery access in percutaneous coronary intervention (PCI). Dose-area product (DAP) was measured non-randomised for 114 procedures using femoral access and for 55 using radial access. The patients also responded to a questionnaire concerning discomfort and pain during and after the procedure. The mean DAP was 69.8 Gy cm(2) using femoral access and 70.5 Gy cm(2) using radial access. Separating the access site from confounding factors with a multiple regression, there was a 13% reduction in DAP when using radial access (p=0.038). Procedure times did not differ (p=0.81). Bed confinement was much longer in the femoral access group (448 vs 76 min, p=0.000). With femoral access, there was a significantly higher patient grading for chest (p=0.001) and back pain (p=0.003) during the procedure and for access site (p=0.000) and back pain (p=0.000) after the procedure. Thirty-two femoral access patients (28%) were given morphine-type analgesics in the post-procedure period compared to three radial access patients (5%, p=0.001). DAP does not increase when using radial instead of femoral access and the patients grade discomfort and pain much lower when using radial access. Radial access is thus beneficial to use.
Aged↗
Comparison between two on-line reversed line position hemodialysis vascular access flow measurement techniques: saline dilution and thermodilution.
Periodical access flow measurements can predict the development and presence of vascular access flow-limiting stenosis and subsequent thrombosis. Access flow measurement has become a standard in vascular access care. Different techniques to measure access flow are available. The aim of this study was to compare an integrated access flow measurement device, based on thermodilution (Blood Temperature Monitor, BTM, Fresenius Medical Care, Bad Homburg, Germany), with the gold standard, the HD01 (Transonic Systems Inc., Ithaca, NY), whose technique is based on saline dilution. In 40 patients with end-stage renal disease, 40 vascular accesses were studied to determine the correlation between access flow measurements by both techniques. Reproducibility of access flow measurements by both techniques was assessed in 20 patients on a weekly interval.A total of 40 measurement series were performed. Average access flow measured with the saline technique and the thermodilution technique was 1053 (+/-495) ml/min and 1034 (+/-527) ml/min, respectively (p = ns) (n = 40). Correlation between access flow measurements by both techniques expressed in R was 0.79 (r = 0.89). Reproducibility of saline and thermodilution subsequent measurements with a weekly interval, expressed in relative difference (Delta xrel) was 13 (+/-11)% and 24 (+/-14)%, respectively (p < 0.01) (n = 20).BTM access flow measurements correlated well with the HD01 access flow measurements. However, the better reproducibility of HD01 and shorter measurement time compared with BTM access flow measurements should be considered when implementing access flow measurement to prevent vascular access failure.
Body Temperature↗
Influence of intravenous drug abuse on vascular access placement and survival in HIV-seropositive patients.
BACKGROUND: The influence of intravenous drug abuse (IVDA) on hemodialysis access placement practices and access survival in HIV-infected patients is unknown. METHODS: We conducted a retrospective study of 60, HIV seropositive, maintenance hemodialysis patients. Type of access and assisted access survival (measured from date of placement) were compared in those with (77%) and without (23%) a history of IVDA. RESULTS: Mean age was 37.8 years, mean baseline serum albumin was 2.9 g/dl and median CD4 count was 222 cells/mm3. Fifteen patients, all IVDA, were dialyzed using only tunneled catheters (median number of catheters per person (range): 2.5 (1-11)). There were longer delays in creation of a permanent access (p = 0.08), but no difference in the type of permanent access placed in IVDA versus the non-IVDA group. Over 1,051 cumulative months of access follow-up, 134 tunneled catheters, 28 grafts and 19 fistulae were placed, with observed failure rates of 1 per 4.7 access-months, 1 per 19.7 access-months, 1 per 38.2 access-months, respectively. The adjusted relative hazard of access failure for grafts versus catheters was 0.41 (95% CI: 0.23, 0.72; p = 0.002) and for fistulae versus catheters was 0.21 (95% CI: 0.08, 0.52; p = 0.001). Thirty-two percent of accesses were removed due to infection, an infection removal rate for catheters of 1 per 7.8 access-months and for grafts of 1 per 62.5 access-months; all graft infections occurred in the IVDA group. No fistula was removed due to infection. CONCLUSION: Fistulae are the first line of choice for hemodialysis access in HIV-seropositive patients regardless of IVDA history; if not feasible, graft placement in non-IVDA or abstinent IVDA patients is recommended. In those with active IVDA, the optimal method of renal replacement therapy and type of hemodialysis access remain uncertain.
Adult↗
Impact of percutaneous access point number and location on complication and success rates in percutaneous nephrolithotomy.
OBJECTIVES: Percutaneous nephrolithotomy (PNL) is sometimes associated with complications, especially in patients with complex stones. Herein, we review our experience with PNL to determine the impact of percutaneous access number and location on success and complication rates. PATIENTS AND METHODS: During a 2-year period, a total of 275 patients with a mean age of 42.3 +/- 14.8 (range: 13-75) years underwent PNL. Stones were classified as simple in 51.6%, and complex (staghorn calculi or renal pelvis stones coexisting with caliceal stones) in 48.4%. Percutaneous access was done under C-armed fluoroscopy and the tract was formed with a high-pressure balloon dilation system. One single percutaneous access was sufficient in 210 (76.4%), while 2 accesses were utilized in 44 (16%), and > or =3 accesses in 21 cases (7.6%). Supracostal access was performed in 23 (8.4%) patients. RESULTS: An overall success rate of 94.9% was achieved. Stone location, but not the access point location, was the major determinant for success, which was 99.3 and 90.2% in patients with simple and complex stones, respectively (p < 0.01). Significant complications included bleeding necessitating blood transfusion in 28 (10.2%), and hydropneumothorax in 2 (0.7%) patients. Bleeding was observed in 39.1 and 7.5% of patients managed with supracostal access, and subcostal access, respectively (p < 0.01). An increased number of access points significantly augmented the risk for bleeding. Bleeding was encountered in 7.6% of patients managed with 1 percutaneous access point, and in 18.5% of cases managed with > or =2 access points (p < 0.05). Hydropneumothorax occurred in patients with supracostal access. CONCLUSION: Supracostal access as well as multiple punctures may be needed especially in the management of complex stones, and the need for multiple access points and supracostal access significantly increases complication rates.
Adolescent↗
[Analysis of the survival of permanent vascular access ports].
Complications arising from vascular access are major causes of morbidity in patients on renal replacement therapy. They contribute to frustration of health care providers and to high medical cost. To prevent failures in the future it will be helpful to identify the factors that are related to vascular access, malfunction. In a retrospective analysis we analysed the types, duration and primary patency rate of 1,033 permanent vascular access in 544 consecutive patients established during a 13-year period in a tertiary care hospital. Patient characteristics, incidence and risk factors related to vascular access failure were registered. In addition vascular access outcomes in patients who started haemodialysis with a catheter and in whom initial vascular access failure occurred were analysed separately. Forty-five per cent of patients required a central catheter at the start of HD, but 92% of them were being dialysed with an a-v fistula at the last observation. The total number of complications was 0.24 episodes per patient per year at risk, and the rate of thrombosis 0.1. A total of 52% of patients were dialysed throughout the observation period with their initial a-v fistula; 9.3% had more than three episodes of vascular access failure. The radiocephalic a-v fistula was the access with the best median duration, exceeding 7 years, but also the type that had the highest initial failure rate, i.e. 25% of patients and 13% of events. The brachiocephalic a-v fistula was the second most frequent type of vascular access, with a median duration of function of 3.6 years, in contrast the humerobasilar a-v fistula, lasted on average over 5 years. Average patency of the different types of grafts did not exceed 1 year, with the exception of the autologous saphenous graft with a median duration of function of 1.4 years. Patients with glomerulonephritis had the best function rates for their access, the median duration exceeding the duration of the study, whereas in half of diabetic patients it was less than 1 year. The duration of patency of the vascular access was twice as long in patients below age 65 years and in elderly males compared to elderly females. Patients who start HD with a catheter, as well as those with initial vascular access failure, have a higher rate of access failure in the subsequent course on renal replacement therapy. In conclusion, the radiocephalic and the brachiocephalic a-v fistula are the two types of vascular access with the longest duration of function, although a high rate of initial failure is seen with the radiocephalic a-v fistula. Age, female gender, presence of diabetic nephropathy, start of dialysis with a catheter, and failure to wait for initial maturation of vascular access are risk factors, and account for the majority of vascular access failure during renal replacement therapy.
Adolescent↗
[Fistulae or catheter for elderly who start hemodialysis without permanent vascular access?].
UNLABELLED: Autologous access is the best vascular access for dialysis also in older patients and it should be mature when patient needs hemodialysis. It is not always possible. Surgeon availability and demographic characteristics of patients (age, diabetes, vascular disease...) are factors that determine primary vascular access. AIM: To analyse outcome and vascular access complications in elderly who start hemodialysis without vascular access. PATIENTS AND METHODS: All patients older than 75 years who initiated hemodialysis without vascular access between January 2000 and June 2002 were included, They were divided en two groups depending on primary vascular access. GI: arterio-venous fistulae. GIIl: Tunnelled cuffed catheter. Epidemiological and analytical data, vascular access complications related, as well as patient and first permanent vascular access survival from their inclusion in dialysis up to December 2002 were analysed and compared in both groups. RESULTS: 32 patients were studied. GI: n = 17 (4 men) and GIIl: n =1 5 (8 men), age: 79.9 +/- 3.8 and 81.7 +/- 4 years respectively (ns). There were no differences in sex and comorbidity (diabetes, ischemic heart disease, peripheral vascular disease and hypertension). It took GI 3 months to get a permanent vascular access suitable for using, while it took GIIl 1.3 months (p < 0.005) The number of temporary untunnelled catheters was higher in GI (3.35 vs 1.87 p < 0.05). Vascular access complications: 70.6% of infections occur in GI (incidence (I) = 48 infections/100 patients-year) while only 29.4% were detected in GII (I = 25 infections/100 patients-year). 70% of central venous thrombosis happen in GI (I: 25 CVT/100 patients-year) vs 30% in GIIl (I = 14.4/100 patients-year) (ns). No significant differences neither in bleeding (66.7% vs 33.3%) nor ischemia (75% vs 25%) were found. Dialysis dose (Kt/V) as well as anaemia degree were similar in both groups. Permanent vascular access survival after 2 years was 45.8% in GI and 24% in GII (ns). Patient survival was similar in GI and GII (72% vs 51% ns). CONCLUSIONS: Elderly who start hemodialysis without vascular access took longer to get a suitable permanent vascular access when arterio-venous fistulae is placed than with a tunnelled cuffed hemodialysis catheter. As a consequence, vascular access complications are larger, infection ones are the most common. In these patients a tunnelled catheter should be inserted at the time a peripheral arterio-venous access is created, in order to avoid temporary untunnelled catheters.
Aged↗
Implementation of Advanced Access in general practice: postal survey of practices.
BACKGROUND: Advanced Access has been strongly promoted as a means of improving access to general practice. Key principles include measuring demand, matching capacity to demand, managing demand in different ways and having contingency plans. Although not advocated by Advanced Access, some practices have also restricted availability of pre-booked appointments. AIM: This study compares the strategies used to improve access by practices which do or do not operate Advanced Access. DESIGN OF STUDY: Postal survey of practices. SETTING: Three hundred and ninety-one practices in 12 primary care trusts. METHOD: Questionnaires were posted to practice managers to collect data on practice characteristics, supply and demand of appointments, strategies employed to manage demand, and use of Advanced Access. RESULTS: Two hundred and forty-five from 391 (63%) practices returned a questionnaire and 162/241(67%) claimed to be using Advanced Access. There were few differences between characteristics of practices operating Advanced Access or not. Both types of practice had introduced a wide range of measures to improve access. The proportion of doctors' appointments only available for booking on the same day was higher in Advanced Access practices (40 versus 16%, difference = 24%, 95% CI = 16% to 32%). Less than half the practices claiming to operate Advanced Access ((63/140; 45%) used all four of this model's key principles. CONCLUSION: The majority of practices in this sample claim to have introduced Advanced Access, but the degree of implementation is very variable. Advanced Access practices use more initiatives to measure and improve access than non-Advanced Access practices.
Adolescent↗
The surgically created arteriovenous fistula: a forgotten alternative to venous access.
The care of patients requiring lifelong intravenous access was revolutionized with the development of tunneled catheters and implantable ports. These devices are not without complications, however, and selected patients may benefit from alternative modalities to maintain access for such therapies as parenteral nutrition, phlebotomy, or chemotherapy. Use of surgically created arteriovenous (AV) fistulae as an alternative to central venous access has been described. This report reviews our experience using AV access for central venous access. An AV access database of more than 800 active patients was reviewed and all patients who had autogenous or synthetic AV fistulae created exclusively for central venous access between July 1, 2001, and December 31, 2003, were identified. Outcomes were assessed. A total of 853 new accesses were placed during the time period. Six fistulae in six patients (0.7%) were placed for central access. All patients (5 males, 1 female, mean age, 42.8 years) required access for intermittent parenteral nutrition or intravenous fluids secondary to short-gut syndrome (n = 5) or gastroparesis (n = 1). All patients had failed at least two prior catheter-based accesses before access placement was considered. Procedures were all brachial artery based and included autogenous brachiobasilic vein fistulae with elevation or transposition (n = 3), autogenous brachiocephalic fistula (n = 1), autogenous brachiobasilic graft with transposed greater saphenous vein (n = 1), and a prosthetic brachiobasilic graft with ePTFE (n = 1). There was one perioperative autogenous fistula thrombosis treated with thrombectomy and revision. A total of seven late revisions (thrombectomy, thrombectomy with venous outflow revision, fistula elevation, and 4 percutaneous angioplasties) in four patients were required. All fistulae were patent and functional at the end of the review period (mean follow-up, = 393 days; range, 35-757 days). Daily access was performed by family members (n = 2) or nurses (n = 4). One patient received small bowel transplantation and no longer required use of his patent fistula. One patient died of liver failure 382 days after fistula placement with a patent fistula. These results show that, while often forgotten and infrequently used, AV access can be a durable alternative to catheter-based venous access.
Adult↗