Hi m name is Monika and i am 46 years old with short bowel syndrome with a current Hickmens. A week ago i had a AV fistula made for TPN. I wont to know will the fistula handle the TPN long term. I septable to infection all the time. I had be told by myy vascular surgeon that my fistula will mite not last due to the fact that the veins are small and i have low blood pressure. What is very ones thought.
I think your surgeon is correct. I have never seen an AV fistula used for this purpose but would have serious reservations about infusing parenteral nutrition through it. Veins of the arm are not large enough with enough volume of blood flow to adequately dilute the parenteral nutrition, which will be a highly concentrated solution and very prone to causing vein irritation. Thrombosis will be the greatest risk from the very limited amount of clinical studies on this practice. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Bless your heart! You've been through so much! What an interesting vascular access option your treatment team decided on for chronic TPN. Seems like the existing tunneled catheter would have been great for this purpose. I would even have leaned towards an implanted port...if you're going to be accessing a fistula, you might as well be accessing a chest or arm port!
My heart goes out to you and I wish you the best of luck on your journey!!
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
At the AVA Convention in Nashville a few years ago, this topic was discussed! AV fistulas ARE used for long term access. The blood flow from the fistula is greatly increased so dilution would not be a problem. The vessels above the fistual will enlarge just as they do for dialysis access. I thought it was a very novel approach to limited access. I would not hesitate using it for TPN.
My notes from the convention were on my IPAD that unfortunately died on me and all content was deleted, but I clearly remember this talk. I will try to find the name of the speaker on the AVA site and post it here.
Wendy Erickson RN
Eau Claire WI
I believe it was the talk on Nephrology Considerations and Alternative Access for the Very Long Term by Dr. Vandana Niyyar and Dr. Christopher Carsten. I did a brief search and found that AV fistulas are used for hemophiliac patients as their access. So it is being done. If you search these doctors' names, you can pull up videos of their presentation - at least I found Dr. Niyyar's online.
Wendy Erickson RN
Eau Claire WI
Monica,
Would you ever be a candidate for transplant?
Angelo M. Aguila, MSN, RN, VA-BC
Vascular Access Nurse
[email protected]
Hi Monika,
I had an AV graft placed back in 99 and with a few hiccups it worked well until 2009, I then went to a port, which I still have, but due to poor technique on the surgeons behalf I never got to use the 3rd AV they inserted. I also have poor veins, hence graft not a direct fistula. So using your fingers you will see it lasted a good 10yrs, I have never had an infection, and only 2 people were ever allowed to access it or even connect the tubing together. So don't believe all you read in headings... a lot of that was from the 1980s. I know Chris Carsten and he is about to do his write up on the over 60 patients with NON dialysis AV shunts/grafts, so you are not alone in the USA. In Europe there is a large number of folk using it, Geert Wanton is a great nucleus of research and belief, here is one article and you can go from there, this one is on nutrition but gives you the details for further searching. http://ajcn.nutrition.org/content/85/5/1171.full
Also down in NZ and Australia and some increase in numbers in Japan.
As I was told at the beginning of my 13yrs on TPN, its far easier to start with an AV and then go to a tunnelled line than the other way around.
Our biggest barrier is that nurses insist on using the AF, for putting in a PIV and so damaging the veins.
Hope this helps, and remember you don't have to have an infection, I refused to and so didn't.
good luck
This is a new method of TPN administration for me but I must agree with Lynn. The hemodilution of TPN in a AV fistula placed in the arm of a patient with already small veins seems like a high risk for failure. From a theoretical standpoint, if an AV fistula developed into a vessel with the same volume and flow, a vessel that is SVC-like would safely tolerate TPN. The SVC is said to be 2cm in diameter (about 6cm circumference) and 7cm in length. Which would be slightly smaller than a 20ml BD syringe barrel. Now 20mls of blood does not sound like much hemodilution but, the SVC flow rate according to Hjortdal(http://circ.ahajournals.org/content/108/10/1227.full) is about 25ml/sec resting and 40ml/sec with exercise. Then you would have a SVC-like AV fistula. This will be an interesting topic to search the literature about.
R. Terry Jones, RN, CRNI, VA-BC
Memorial Hermann Northeast Hospital
Humble, Texas
Remember an AV fistula is an artery connected to a vein so the increased arterial blood flow causes enlargement of the vessels that are having to accomodate the flow. AV fistulas for dialysis patients allow blood flow rates of over 300-400 cc/minute. The TPN would be infused into the enlarged veins above the fistula. Having an extensive dialysis background as well as vascular access and nutrition support, I think these are a great idea!
Wendy Erickson RN
Eau Claire WI