Policy and Procedure N0. 017 – Royal Hospital
PURPOS‎E
1. To maintain patency of the fistula.
2. To prevent the occurrence of complications.
POLICY
1. The procedure is explained to the patient by the physician and consent is obtained
2. The operation is performed under Brachial Block or General Anaesthesia
3. Vessels in the arm intended for AVF should not be punctured for any reason except for life saving procedures.
4. In case of venography, puncturing should be performed in the veins of the dorsum of the hand and NOT on the inner aspect of the arm
5. Nil by mouth is maintained for 6-8 hours prior to surgery
6. All blood investigations should be available prior to surgery.
PROCEDURE
I – PRE-OPERATIVE CARE
1. Perform skin preparation of the arm from the shoulder to the wrist including the armpit.
2. Have pre-medication available, if required.
II – POST-OPERATIVE CARE
1. On return to the ward, give the usual post-operative care according to general post- operative policy.
2. Keep the arm elevated on a pillow.
3. Check for the thrill and listen for bruit to ascertain the patency of the fistula.
4. Report immediately when the thrill or bruit is absent.
5. Report if any, cyanosis, pallor, and / or numbness of fingers.
6. Note an oedema of operated arm.
7. If bleeding occurs, inform the physician immediately and change dressing. 8. Observe wound site for further bleeding.
9. Inspect wound on 3rd post-operative day. Remove dressing and apply opsite spray over the wound site.
10. Instruct patient not to use tight watch, tight clothes, jewelry (rings or bracelet) in the operated hand especially the first 48-72 hours.
III – HAND EXERCISE
1. Give soft cotton ball (size of tennis ball) rolled in gauze to the patient. Instruct patient how to place the ball in the palm of the fistula arm and grip it lightly for 5 seconds (count 1 to 5) and release. Patient has to do this exercise – immediately after recovery – three times a day for the vein to become prominent.
POSSIBLE COMPLICATIONS
1. Oedema of the arm
2. Haemorrhage
3. Infection
4. Ischaemia of the hand
5. Endocarditis due to bacterial infection
6. Congestive heart failure
7. Thrombosis due to slow circulation or failure technique of anastomosis
8. Pseudo-aneurysm due to early use of the fistula before thickening of the walls of the veins
9. Embolism
ADVICE TO THE PATIENT
1. Avoid pressure on the fistula arm
2. Avoid wearing tight watch, jewelry or clothes on the fistula arm
3. Avoid the habit of using the fistula arm as armrest while sleeping
4. Continue hand exercises till further instructions from nurses
5. Avoid carrying heavy items by the fistula arm
6. Avoid excessive shaking of fistula arm
7. Keep the area clean and hygienic
8. If any bleeding occurs, apply pressure and report to the nearest medical centre immediately.
Reviewed and approved by Dr. Mohammed Ali Jaffer,
Senior Consultant, Head of Division of Surgery, Royal Hospital
January 2001