Reflective Report On Complications And Interventions In A Clinical Setting

This reflective summary paper, as part of a workplace clinical assessment, will discuss complications and interventions in our unit and areas of competency. This is in order to solve areas of improvement and any further issues.

The first discussed topic will be fistula stenosis. Fistula stenosis is considered as the vascular access of choice for HD due to the low rate of complication. During my assessment, I had noticed that some of my hemodialysis patients have never achieved an adequate kt/v, ever since the starting of their dialysis. During my physical examination of fistula, I found abnormal findings such as a high venous pressure, prolonged bleeding time, reduced blood flow, recirculation and pain during treatment. I saw these symptoms so I referred properly and due to the early detection, the overall outcome was good. Early recognition and treatment of vascular insufficiency resulting from fistula creation, is vital in reducing the mortality which is associated with hemodialysis.

So I referred to the vascular clinic and diagnosed venous stenosis by doing a Doppler scan. As I am competent with fistula stenosis, I am able to manage such situations with knowledge and in a correct manner. One of the main causes of early fistula failure is stenosis anywhere within in the AVF circuit. Stenosis is known as narrowing of the blood vessel and slows down the flow of blood through access and this means that not getting efficient dialysis and it is also considered as the major cause of dysfunction of an arteriovenous fistula. Balloon dilation is considered as the first line in therapy, further interventions such as stent placement or surgical revision are sometimes required in order to treat the stenosis. Another area that I see myself competent is in ultrasound-guided cannulation of haemodialysis access. Ultrasound-guided vascular access is a very effective method in continuing adequate hemodialysis therapy for some patients.

The amount of patients who undergo difficult arteriovenous fistula cannulation has immensely increased due to the changes that could be seen in the epidemiology of the dialysis population. As per the KDOQI guidelines, it states that a functional permanent access should be less than 0. 6 cm below the surface of the skin. The indications of ultrasound-guided AV fistula cannulation are the vessel which is too deep or small for reliable cannulation, a vessel with adjacent artery or nerve, a vessel with multiple histories of numerous attempts is vital.

Several attempts will usually end up resulting with poor patient satisfaction and unnecessary costs. An ultrasound-guided method could possibly have the potential to minimize the damage of AV fistula, which would result in a better prognosis for a patient with difficult access. In our unit, I always tend to promote other staff to use the SonoSite machine, which is a portable ultrasound. Not only does this prevent the failure of needle placement but also enables the correction of the needle tip location. I always make sure that physical barriers such as plastic wrap are used. This is done in order to prevent a potential cross-contamination between the patients.

Ultrasound-guided vascular access can be a very effective method in continuing adequate hemodialysis. To promote ultrasound-guided cannulation, I provided ongoing education by showing them informative videos, also give instruction images as well as encouragement and all the assistance required. In order to achieve this, we need to understand the theory of ultrasound guidance. Patient education is also very necessary to ensure that the importance and advantages and clearly comprehended. Argyle cannulation is an area that I would like to improve on for accessing AV fistula. Recently, we have introduced needleless cannula in our unit and I personally think that is is the better option, from the use of metal needles. There are approximately 300, 000 patients dialysed every week in Japan, mostly using cannula rather than steel needles, with an excellent success rate and minimal complications and there were no reported medical incidents.

One of the advantages of using Argyle cannula is that there is no needle in the cannula to infiltrate the vessel during the dialysis session. Argyle cannula is a good choice with confused patients who regardless of education, and reinforcement still manage to move their arms and inevitably end up with infiltrated vessels. In occasions where an arteriovenous fistula has to be accessed for intravenous infusion the dialysis cannulas. With the anti-reflux valve or cannulas with a silicone valve, it provides a much safer insertion than regular intravenous cannulas and has a larger bore size. Argyle cannulas are safe for new fistula. It is also a better option and it will become more common for restless kids, patients with metal allergies and patients on long dialysis sessions.

The benefits of Argyle needle, as compared to metal needle includes; cost efficiency, great for patients with tremor and movement as it’s plastic. I found it very useful within the unit and realized the advantages.

Overall, this assessment allowed me to improve my skills and gain more knowledge and insight into my strengths and weaknesses. It also helped me to realise the importance of education in order to attain competency in important areas of health, as it is very beneficial and it enables us to provide the best care possible for all patients.