Hello,
Yesterday a 66 y.o. WF with CKD in ICU needed a PIV for CT scan of the abdomen and I was called for assistance. She has a working fistula to her left upper arm and a non-working fistula to her right upper arm. The dialysis nurse was standing by to hook the patient up to hemodialysis immediately post-CT. I know the Standard which states no venipuncture on the extremity containing an AV fistula or graft. I told them she needed an IJ. The patient was vomiting with abdominal pain and in some distress. CT was waiting to take her after she had an IV. There was a PIV to her right hand infusing and I told the nurse (quietly) that IV should come out. I started the PIV to her right arm (non-working fistula) just below the antecubital with a #20 gauge using ultrasound guidance, but with instructions to remove immediately post CT and get an IJ in.
What would anyone else have done? What should I do next time? I feel like I should have said "no" and get an IJ but with active vomiting I did not think that would happen.
Thank you.
Carole
This is not a completely black and white issue. The INS Standard 33 Site Selection calls for knowledge of the stage of renal failure and a collaborative discussion with the patient, LIP about the choices of sites but it does not say "do not use any extremity with a fistula". In this situation, you have an extremity with a nonfunctioning fistula, a patient in serious need of a diagnosis, and hemodialysis ready to begin following the CT through a functioning fistula in the opposite arm. I certainly would have placed the PIV as you did and after a discussion with the nephrologist knowing the outcome of the CT and hopefully a more firm medical diagnosis, then decide what type of VAD would be required for the needed length of therapy. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
OK. Thanks for your insight.
Carole
I totally agree here. Keys: critical thinking and teamwork with all disciplines.