NOAH HENRY, 72, arrives in your unit from the ED for a 23-hour stay. He appears anxious and short of breath. He has a left forearm prosthetic arteriovenous graft (AVG) for hemodialysis. Mr. Henry was scheduled for dialysis at 7 a.m., but the dialysis staff told him they'd have to notify his nephrologist because his AVG "wasn't working."
What's the situation?
Mr. Henry is upset and wants to know when he'll have his dialysis treatment. His last treatment was 2 days ago. His vital signs are BP, 186/98 mm Hg; heart rate, 96; and respirations, 24. When you assess him, you note 2+ pitting edema of his feet and ankles and fine bibasilar inspiratory crackles on lung auscultation. He has a soft, harsh, holosystolic cardiac murmur you can hear best at the apex. You can't auscultate a bruit over the left forearm AVG or palpate a thrill (a vibrating or purring feeling) anywhere along the hemodialysis access.
What's your assessment?
Mr. Henry's dialysis access most likely is clotted, a common complication of AVGs. The vascular surgeon will decide whether to send him to the interventional radiology suite for a renal dialysis access study (also called a fistulogram) with probable fibrinolysis and percutaneous transluminal angioplasty (PTA), or to the OR for a surgical thrombectomy and revision.
What must you do immediately?
Notify Mr. Henry's nephrologist of the situation. Missing a hemodialysis treatment increases your patient's risk of life-threatening fluid and electrolyte imbalances such as hyperkalemia. Send blood specimens for stat electrolytes, blood urea nitrogen, creatinine, complete blood cell count, and coagulation profile. Reassure Mr. Henry and administer supplemental oxygen by nasal cannula to help him breathe. Monitor his SpO2.
Weigh Mr. Henry and keep him N.P.O. because he'll most likely need moderate sedation and analgesia. Ask him when he last ate or drank anything, and document it in the medical record. Ask if he has any allergies and establish I.V. access in the contralateral arm if ordered.
Based on lab results, the surgeon decides that Mr. Henry can undergo hemodialysis after PTA or thrombectomy of his AVG. If he needed stat hemodialysis, he'd also need placement of a central venous access device.
Mr. Henry is sent to the interventional radiology suite, where his thrombosed AVG is successfully declotted after fibrinolysis and PTA of the venous anastomosis.
What should be done later?
When Mr. Henry returns, assess the AVG, which now has palpable thrill and good bruit. Check for the thrill and bruit every 2 hours until Mr. Henry is sent for hemodialysis. If the thrill or bruit decreases or disappears, or you note excessive bleeding, contact the interventional radiologist immediately.
Be sure to forward the required information to the dialysis center where Mr. Henry receives treatment. Teach Mr. Henry how to keep his AVG working. For example, he should check for a thrill and call his health care provider or hemodialysis nurse immediately if he notices a change. Make sure he knows not to wear tight clothing or jewelry on his access arm and not to let anyone take his BP or draw blood from his access arm.