Well yesterday I had a bit of a fright at 2.30am….nope, not nightmares but rather some brush with gangsters and gangs – all hypothetical, but still. I browsed through my blog and was impressed with what volume I was able to write before I started the 200hours haemodialysis training. Now as I near the end, its a bit sad, but at the same time, I’m glad to move on.
Just wanted to make some brief notes of the AV fistula clinic, since its part of the requirement to see pre-op and post-op counselling of patients.
There’s a mix of patients of course. What sort of surprised me was one patient who seemed unsure what exactly he was there for. So the surgeon had to explain that he was stage 5 chronic kidney disease, soon, though we can’t say exactly when, it is likely he will need haemodialysis, and the purpose of the clinic is to assess and see if the patient is suitable candidate for creating an AVF, and then to get an appointment. At first the patient was not too keen, something to do with having to travel far and being inconvenienced.
Then the surgeon reasoned, it is better to get the AVF now while your vessels are good and untouched. Once a person has fallen ill and requires hospitalization, there will be a lot of needle puncturing and this makes the procedure more difficult. He agreed to proceed.
Past medical history. If the patient has ischaemic heart disease, or risk factors of, they will be asked regarding symptoms. I have seen patients who are symptomatic, short of breath on exertion, 2 or more pillow orthopnea, swollen legs, and they are asked to come back after further HD so that they can be re-assess. The procedure cannot be done if patient is in heart failure because it will require good arterial blood supply to create a successful AVF. All or at least most patients will have echo results accompanying their referral notes.
Then the surgeon will have a look at the arms. The non-dominant arm is chosen. A tourniquet is placed to bring out the veins. The ultrasound machine is used to measure the size of the vein and artery and a decision is made whether the surgery will be at the level of radio-cephalic, brachio-cephalic or higher: basilic-fistula. Attempts will be to try as proximal as possible, if unsuccessful, to go higher up during surgery, which is done using local anaesthetic. Most patients are admitted one or two days before, either to make sure parameters like blood pressure etc is optimal, or if patient lives far away, to allow early morning operation.
Patient is advised to exercise and is given an exercise ball, this will increase the size of the veins. Plus, all blood taking and blood pressure measurement is to be avoided on the chosen side. No tight clothing, no compression during sleep or by children or grandchildren.
For one week after surgery, no heparin is to be given during HD. Of course at this time the patient is using another type of access, usually IJC. Usually the patient will return after one month for assessment. The surgeon looks and may measure the vessel size. In some patients the decision to use is made at that point, but for the majority, it is after 2 months. Once the vein reaches 5mm in diameter using US and 2mm from surface, it can be used. If there is a long strip, the patient will be advised to use different areas for cannulation during HD as to avoid the formation of aneurysm and weakening of the vein wall.
Most patients return again after the AVF has been used for sometime. If all is well, they are then discharged from the clinic.