MATERIALES EDUCATIVOS
Literatura científica
| Patients at risk of VND quotation | Reference |
| Venous needle dislodgement is a potentially life-threatening complication of dialysis that can happen to anyone in any dialysis setting throughout the world. | Hurst 41 Axley, B et al 43 |
| Patients with a well functioning AV fistula e.g. p> 25mmHg, amounts to 50% of all AV fistulas. | Polaschegg H-D1 Polaschegg H-D18 |
| Low/poor lightning in the room | Hurst J 11,37, Mactier et al 15 |
| Patients experiencing restlessness towards the end of the dialysis Restlessness throughout | Hurst J 11,12,37 Mactier et al 15 Liback-Pedersen L 13 Polaschegg H-D 2 VA Patient Safety Advisory 16 VA Patient Safety Advisory 17 |
| Patients with frequent blood pressure drops or muscle cramps | McCabe M 8a Axley, B et al 43 |
| Patients covering the access during dialysis, this includes patients who are cold, sleeping, and are typically patients in beds | Hurst J 11,12,37 Lindley E 10 Polaschegg H-D 1,2 Sandroni S 4 Liback-Pedersen E 13 Almen 7 VA Patient Safety Advisory 16 VA Patient Safefy Advisory 17 Axley, B et al 43 |
| Patients with extensive hair growth around the access points, which makes fixation of the needles more difficult. Patients with skin conditions; allergies to patches, eczemas, extensive sweating | Van Waeleghem, J-P et al 9 McCabe M 8,8a VA Patient Safety Advisory 16 |
| If venous pressure before treatment is below 25mmHg, the patient should be regarded as “high risk” for VND | RPA. Keeping Kidney Patients Safe 45 |
| Patients on nocturnal and/or home dialysis | Axley, B et al 43 |
| Patients with history of VND | |
| Patients who are mentally, cognitive, neurological impaired Ex. Dementia, patients not understanding the implications of a VND, reduced sensitivity Patients who are uncooperative Patients who are agitated | McCabe 8a Mactier et al 15 Van Waeleghem, J-P et al 9 Liback-Pedersen E 13 Polaschegg H-D 2 VA Patient Safety Advisory 16 VA Patient Safety Advisory 17 Axley, B et al 43 |
| Patients with fistulas located other than cephalica or brachea, e.g. locations which are not visible easily submitted to friction | Van Waeleghem, J-P et al 9 Mactier et al 15 |
| Patient with known small blood leakage oozing around the venous needle | Van Waeleghem, J-P et al 9 McCabe M 8a |
| Patients with diabetes and frequent hypoglycemic episodes during HD therapy | McCabe M 8a |
| All patients dialyzing with limited or without supervision e.g. Sleeping, Nocturnal Self care/Low care Home Isolation rooms in clinics, ICU | Van Waeleghem, J-P et al 9 McCabe M 8a Almen 7 Sandroni S. EDTNA disc. Forum 10 Lindley E 10 Hurst J 11,12,37 VA Patient Safety Advisory 16 VA Patient Safety Advisory 17 Axley, B et al 43 |
| Minimizing the risk of VND requires a combination of human skills, vigilance and technology | Van Waeleghem JP et al 26 |
| Patient and staff awareness is important | Hurst 37 Axley, B et al 43 |
| High acuity patients and patients with an altered mental status have a higher risk of VND | Martin Lascano 40 |
| VP alarm failed to detect VND until significant blood loss Pressure drop caused by a cannula slipping: such event isusually too small to be detectable by the venous pressure monitor VP measuring is an unreliable method for detecting needle dislodgement Venous needle dislodgement during hemodialysis without triggering the venous pressure alarm was reported in an online medical device safety report from 1998 Study to examine the success rate of VND detection in different types of dialysis access, using the venous pressure monitoring system. Only 29% of fistula VNDs were detected related to discrepancies in pressure. | VA Patient Safety Advisory 16 VA Patient Safety Advisory 17 Sandroni S 3 Almen 7 Polaschegg H-D 1 Van Waeleghem JP et al 26 Polaschegg H-D 18 Pennsylvania Safety Advisory 35 Axley, B et al 43 Ribitisch, W et al 44 |
| Incidence and severity of incidents of VND | |
| 1/126 718 treatments, a catastrophic hemorrhage with 33% mortality = 136 deaths/year (=2/week) 1/62 500 serious bleeding (include cath & needles = 2/day) 5% has a needle come out (=200/day) 6.1% VND incidents (review of all type of incidents 562 over 1 year) 0,1% VND incidence rate 1/500 000 death 3% of treatments bleeding leading to corrective action (0,9% complete VND) Post VND higher mortality risk due to infections VND incidents are underreported VND remains the most common cause of preventable death in dialysis and is a serious risk for the home patient. 414 episodes of fatal VND episodes are likely an underestimate Without doubt VND is the most unexpected and potentially lifethreateningcomplication in dialysis. | Sandroni S 4 VA Patient Safety Advisory 16 RPA Renal Physicians association 19 Pennsylvania Safety Advisory 35 Almen 7 Derek White, Gambro 20 T. Court: Physicist engineer (PhD) Gambro R&D 21 Derek White, Gambro 20 Robin Fields, Probuplica 25 Peter Laird 39 Martin Lascano 40 Hurst 41 |
| Cost related to VND | |
| VND Costly complication Minor VND 522-1183$/blood transfusion Sever VND 4 days hospital/blood/EPO/Plasma expanders… 114 000$ and up Liability costs | Hurst 22 Hurst 41 |
| Cost of blood transfusion 522-1183$/transfusion | Shander 23 |
| Minimization of undetected VND | |
| Minimization of undetected VND episodes can be aided by use of blood loss detection devices | Martin Lascano 40 |
| Cost of blood transfusion 522-1183$/transfusion | Shander 23 |
| Blood transfusion related to 16% higher long term mortality | Surgenor 24 |
| Only Hospital-operated facilities must report events under the Act 13 of the Medical Care Availability and Reduction of error Act of 2002 (freestanding dialysis clinics are excluded) | Pennsylvania Safety Advisory 35 |
| Electrical Safety | |
| Further a direct electronic sensor such as a moisture or enuresis detector is not suitable since research have shown that a DC 5 V power supply could cause a micro shock by ionization in the skin. | Akihiro T et al 36 |
Listado de articulos.
Revision incluye las siguientes publicaciones
1. Polaschegg, H-D. Neglected Safety Aspects in Hemodialysis Machines and their Related Problems. Hemodialysis Horizons, AMMI, 2006 Page 66.
2. Polaschegg, H-D. EDTNA/ERCA Conference, Prague, September 2008, Seminar, “Venous needle dislodgement: A safety issue. Possible methods for detection and prevention of major blood loss” Page 40.
3. Sandroni S. Venous needle dislodgement during hemodialysis An unresolved risk of catastrophic hemorrhage. Hemodialysis International 2005; 9102
4. Sandroni, S, Shockerman, T, Hayes-Light, K, Catastrophic Hemorrhage from Venous Needle Dislodgement during Hemodialysis, Journal of the American Society of Nephrology, volume 9, November 2008, Abstract issue.
5. Blagg CR. Home haemodialysis: ’home, home sweet, sweet home! “Nephrology 2005:10(3): Page 206–14
6. Esther Saner et al. Outcome of home haemodialysis patients: a case-cohort study. Nephrol Dial Transplant (2005) 20: Page 604–610
7. Ahlmén J, Gydell KH, Hadimeri H, Hernandez I, Rogland B, Strömbom U (2008) A new safety device for hemodialysis. Hemodialysis International 12 (2), Page 264–267.
8. McCabe M, et al, 38th EDTNA/ERCA International Conference Abstract. a. Risk Assessment Tool Dundee
9. Van Waeleghem JP, Chamne M, Lindley, M, Pancirova, J, Venous needle dislodgement How to minimize the risks, Journal of renal Care 2008, Page 163-167.
10. Lindley E, EDTNA/ERCA Journal discussion club summary 2005. www.edtnaerca.org/pages/education/journalclub/summary2005_2.php
11. Hurst, J, Keep an Eye On Your Needle, Kidney Times #312
12. Hurst, J, Venous Needle Dislodgement, Virgo publishing 09/09/2009
13. Liback Pedersen, E. Allvorlig Blodtab under heamodialyse, Dialäsen 5, 2008
14. Cafazzo, J-A. et al, Barriers to the Adoption on Nocturnal Hemodialysis, American Society of Nephrology 2009, ISSN:1555-9041/404-0784
15. Mactier, R, Worth D, Artery Issue 41, March 2007
16. Patients Safety Advisory; Veteran Health Administration Warning System; Published by VA Central Office; October 21, 2008
17. Patient Safety Alert, Health Administration Warning System; Published by VA Central Office; July 6, 2010
18. P Polaschegg H.-D. (2010). Venous needle dislodgement: the pitfalls of venous pressure measurement and possible alternatives, a review. Journal of Renal Care 36(1), 41-48.
19. RPA Renal Physicians Association, Health and Safety Survey to improve patient safety in end stage renal disease (2007)
20. Derek White, Gambro; Oral presentation EDTNA Congress Florence 2007 (Oral presentation)
21. T. Court: Physicist engineer (PhD) Gambro R&D – France, Dr M. Chawki Néphrologist ErmontCormeilles en Parisis (95) France 2008
22. Hurst J, A Costly Complication: Venous Needle Dislodgement.
23. Shander, A., Hofmann, A., Ozawa, S., Theusinger, O., Gombotz, H., Spahn, D. “Activity-based Costs of Blood Transfusions in Surgical Patients at Four Hospitals.” Transfusion. April 2010, Volume 50, Issue 4, Pages 753-765
24. Surgenor SD, et al; Northern New England Cardiovascular Disease Study Group. The association of perioperative red blood cell transfusions and decreased long-term survival after cardiac surgery. www.ncbi.nlm.nih.gov/pubmed/19448195
25. Robin Fields, When Needles Dislodge, Dialysis Can turn Deadly. ProPublica, Nov 10, 2010. www.propublica.org/article/when-needles-dislodge-dialysis-can-turn-deadly
26. Van Waeleghem JP, Chamne M, Lindley EJ, Olausson S, Pancirova J, Sundström M, Tattersall JE. Abstract: The tragedy of Venous Needle Dislodgement. ANNA 2011
27. Tricia West, R.N., BSN, MBA/HCM, PHN, LNC, Knowledge is Power.
28. News coverage NBC
29. Robin Fields, In Dialysis, Life-Saving Care at Great Risk and Cost. ProPublica, Nov 9, 2010. www.propublica.org/article/in-dialysis-life-saving-care-at-great-risk-and-cost/single
30. Robin Fields, New Study Shows Higher mortality Risk at Fro-Profit Dialysis Chains, Dec 9, 2010. www.propublica.org/article/new-study-shows-higher-mortality-risk-at-in-for-profitdialysis-chains/single
31. Robin Fields, www.propublica.org/article/dialysis-data-once-confidential-shines-light-onclinic-disparities
32. Robin Fields, www.propublica.org/article/feds-to-follow-propublica-release-dialysis-clinicdata
33. Robin Fields, www.propublica.org/article/sen-grassley-demands-information-on-dialysisclinic-conditions
34. Olsson P. Sundström M. Annotated Pro Publica Articles (25, 29-33)
35. Pennsylvania Patient Safety Authority. Vol 7, No. 3 September 2010. www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Sep7(3)/Pages/87.aspx
36. Takeuchi A, Ishida K, Morohoshi Y, Shinbo T, Hirose M, Ikeda N, Study of light transmission through gauze pad effected by blood or liquids to detect needle dislodgement. J Clin Monit Comput 2010; 24:35–39
37. Hurst Jane, RN, CLNC Venous Needle Dislodgement Precautions. AAKP RENALLIFE July volume 8.
38. J Cowperthwaite, A Rivers, M Sundström, J Hegbrant Abstract & oral presentation. ADC March 2011
39. Peter Laird, MD. Taking Hemodialysis Home Safely. Renal Business today October2011
40. Dr. Martin E. Lascano, Michael Bradley Andersen RN, Cleveland Clinics; Venous Needle Dislodgement Prevention in Hospital Based Hemodialysis. Abstract ASN November 2011
41. Hurst Jane, RN, CLNC, Venous Needle Dislodgement – A Universal Concern. European Nephrology, volume 5, issue 2, winter 2011.
42. Michael Morales, CHT, CCHT-A, CCNT, CBNT, Grace Padilla-Kastenberg, MPH, Venous Needle Dislodgement In Dialysis Clinic Settings. A Special Report. Feb 2013.
43. Axley, B, Speranza-Reid J, Williams H. (2012) Venous Needle Dislodgement in Patients on Hemodialysis. Nephrology Nursing Journal, 39(6), 435445.www.annanurse.org/download/reference/journal/vndArticle.pdf
44. Ribitsch W, Schilcher G, Hafner-Giessauf H, Krisper P, Horina J, Rosenkranz A, Schneditz D. Prevalence of Detectable Venous Pressure Drops Expected with Venous Needle Dislodgement. Seminars in Dialysis. Sept-Oct 2014; 27 (507-11).
45. RPA Renal Physicians Association, Keeping Kidney Patients Safe. Venous Needle Dislodgement. www.kidneypatientsafety.org/didyouknow_needledislodgement.aspx
46. Faratro, R., Jeffries, J., Nesrallah, G. E. and MacRae, J. M. (2015), The care and keeping of vascular access for home hemodialysis patients. Hemodial Int, 19: S80–S92.