48 years old lady has left Brachio-axillary AVG for hemodialysis
DM/HTN/History of IHD
She presented to A&E from dialysis centre with swelling,redness, tenderness around the graft site
She has fever and tachycardia with low BP
What would be your assessment plan
What should be your initial management plan in A&E
What would be your investigation plan
The CTA you have done shows collection around the graft with gas and WCC is 21,000 and CRP 284
What would be your management plan
— full lab including cbc and bag for need of HD if indicated, echo and ecg for the prescience of IHD, duplex us on avg for determining if there is collection or psuedoanuerysm which requires urgent exploration
patient needs admission with broad antibiotic coverage and vitals monitoring with the possibility of vasopressors to maintain adequate perfusion if patient is shocked
pus surrounding AVG requires avg excision with brachial and axillary vein control
distal arterial HHD needs to be examined intraoperatively after arterial clamping and before ligation for the need of thrombrctomy and extra anatomical bypass if needed
a case of infected AV graft :
admit the patient and prepare for graft removal and vitals control
initial management :
Take full labs:
vital data monitor and control
soft tissue US
assess for any hard signs or soft signs
check overlying skin condition or punctum point
consider subcutaneous abscess or pseudoaneurysm
investigation plan:
CBC,electrolytes, ABG, coagulation profile, CRP, urea and serum Cr level,
Soft tissue US and duplex examination, CTA
Mangment plan
NPO and crossmatching
good IV antibiotics
blood culture and woundswab culture
arrange for total graft removal and debridement
arrange for mahokar insertion
What would be your assessment plan
admission
full lab (CBC, CRP, ABG, K, ..)
vital data (HR, RR, Saturation)
clinical assessment for puncture site infection grade
What should be your initial management plan in A&E
as above +
if active bleeding or pulsatile hematoma will do localized compression then transfer to OR for exploration and repair
What would be your investigation plan:
LAbs as above
then urgent Duplex US for the arm and graft
The CTA you have done shows collection around the graft with gas and WCC is 21,000 and CRP 284
So, urgent transfer to OR for graft removal and debridement
What would be your management plan
preoperative preparation (Consent including ligation of the artery and limb loss .., blood, full lab, anesthesia consultation)
exposure of the brachial artery first as the inflow,
control and ligation if the infection was likely
exposure of the axillary vein at anastomotic site
ligation
Graft removal and extensive debridement surgically and by H2O2, send to pathology and C/S
wide sutures
A1 i will manage the patient according to ccrisp protocol ABCD
start iv antibiotics
start iv fluid resusitation and avoid fluid overload
rest of AVG
insert temporary dialysis catheter
urgent nephrology consultation for patient dialysis schedule
A2 assessment
measure lactate level
blood culture
ABG and electrolyte especially k
cbc -esr – crp -virology
kidney function test and blood glucose level
A3 investigation post shunt asessmemt to asess inflow and outflow and graft patency any collection
may need CTA
A4 exploration over AVG
excsion of graft
may need ligation of artery and vein
wound culture and debridment
iv antibiotics
monitor patient hand status if it become ischemic
follow up inflammtory markers
1-CBC, Esraa , crp , superficial us (liquefaction or not) , start Iv antibiotics broad spectrum
2- admission, urgent debridement and graft removal , culture ( swab from pus and graft)
I will assess patient according to ABCD approach
Then
Will consider sepsis management
I will insert two wide pore canula
Give fluids if dehydrated
Taking blood sample for culture and sensitivity
Rbg, k, na, abg, Urea, creat
Giving AB according to hospital police
Informe renal registrsr if patient need dialysis
Then
I will ask for CTA
….
Prepare pt for urgent surgery for
Excision of abscess and closure of AVG
….
Insert mahourker
And
Prepare pt for another access by venous mapping
Q1
I will assess patient according to ABCD approach
Then
Will consider sepsis management
I will insert two wide pore canula
Give fluids if dehydrated
Taking blood sample for culture and sensitivity
Rbg, k, na, abg, Urea, creat
Giving AB according to hospital police
Informe renal registrsr if patient need dialysis
Then
I will ask for CTA
….
Prepare pt for urgent surgery for
Excision of abscess and closure of AVG
….
Insert mahourker
And
Prepare pt for another access by venous mapping
>> my assessment plan
This condition suggests infected arteriovenous graft (AVG) with gas forming organism and possible sysemic sepsis,
Clinically:
systemic and localised examination to assess signs of systemic sepsis and the extent of local infection in the upper limb
investigations including full lab with blood culture
>> my plan in A&E
> Resuscitation and spesiss management :
Start IV fluid resuscitation with isotonic fluids to restore BP with consultation of nephrologist to assess amount of fluids.
broad-spectrum IV antibiotics
Monitor vital signs continuously.
vasopressors if BP remains low despite fluids.
>> Investigation Plan
Lab:
Blood culture
Full blood count (WCC high at 21,000).
CRP, KFTs and lactate
Imaging:
CTA findings: Confirmed collection around the graft with gas, consistent with abscess or gas-forming infection.
>> management:
Urgent surgical intervention to control the source with Immediate exploration of the graft to drain the collection and complete excision of the infected graft, and debridement of the infected tissues.
Continue antibiotic therapy, later based on swap and blood culture results
Postoperative:
Monitor of the vital signs and CBC for persistent sepsis.
Assessment of limb vascularity and viability.
follow-up to plan another access after infection resolution.
Very good methodical and systematic approach, well done
Q1
Resuscitation 1 st
Check BP ,HR ,RR and temp
Local exam for crepitus or pus oozing or skin maceration
Good hydration
Antibiotics
Admision
Abg, hb correction
Arrange for surgical interference
Q2
Hydration
Parentral antibiotics
Control glu level
Blood banking
Q3
Us
Cbc
Abg
S.creat
Hba1c
Random blood sugar
Q4
Removal of graft
Ligation of artery
Ligation of vein
Eradicating infection site
Culture taken
Parenteral antibiotics
Reasonable approach and planning
Q1.assessment plan:
General;
Laboratory investigation to asess sepsis and general condition ;Cbc , Abg,electrolytes and kidney functions.
Vital signs data.
Local ;
examination of the limb,peripheral pulsation,swelling assessment and analysis of complaint.
Q2.initial management in the emergency room:
Resuscitation by fluid and stabilization of general condition, lite compression over the arm by crape bandage.
Administration of IV broad spectrum antibiotics ,withdraw cultures.
Blood cross matching.
Q3; investigations:
Cbc,coagulation profile,electrolyte and kidney functions.
Duplex US and superficial US , X-ray.
Q4:patient will need admission and surgical removal of graft and evacuation of collections and ligation of the vissles
Good assessment and management plan
Q1: admission and history taking last dialysis session and asking about her Access history and previous attack and other infected sites or complains
Q2: i will assess the AVG using ultrasound and will give her broad spectrum antibiotics
Q3: duplex ultrasound and full blood count and CRP
Q4: removal of the infected graft and insertion of a permi-acath for dialysis under cover of antibiotics
Good answer
1- assessment of the vital data of the patient, conscious level, blood glucose level, signs of dka, signs of hyperureamia, start resuscitation with fluid challenge, o2 mask,pain control order a cbc, inr, ecg, urea, cr, k, abg, blood culture
History about her medical problems, compliance to medications, quality of dialysis sessions, hx of the avg, the swelling onset, course and duration
Exam : inspection for sinuses at puncture sites, infected or gangeronous skin over pseudoaneurysm , palpation of the swelling pulsatility, induration and flactuation, palpation for thrill or pulse over the graft
2- exclude septic shock, dka, need of urgent dialysis, plan a temporary access, book RBCs and plasma
3- duplex scan on the graft for patency, flow rate, pseudoaneurysms, collections, rupture anastmotic sites
If there perigraft fluid, or extravasation around anastmotic sites a cta is required to assess arterial tree of the limb and patency of radial and ulnar arteries for possibility of graft removal and ligation of brachial A and axillary V
4- prescence of gas means abcess that needs evacuation and according to its extention along the lengh of the graft will decide the salvagability of the graft
If the abcess is limited to the middle of the graft sparing the anastmotic sites, ligation and excision of the infected portion with debridement and generous wash, then bypass in a healthy plane away from the abcess cavity may be an option
If the whole lengh of the graft is infected or ruptured anastmosis removal of the graft with ligation of vessels will be done
Well done , good assessment and planning
A1:General assessment according to CCRISP protocol – sepsis 6
Local assessment distal pulsation -discharge -bleeding
A2: Resuscitation -antibiotics – analgesics – liaise with anesthetist & nephrologist and inform the OR to prepare for intervention
A3: HB, urea and electrolytes and RFTs, INR, ECG,duplex evaluation the AVG, cross match and prbcs, ffps booking
A4: Exploration with proximal arterial control
excision of the graft with the evacuation of the collection and sending C&S
arterial ligation might be considered in case of severe infection
Well done , good assessment and planning
1 assessment plan
Check the vital signs
General and local examination
Complete lab Investigations
2 initial managment
Hospital admission
Secure dialysis access
Iv Antibiotics and iv fluids according to cvp
3 Investigations plan
Complete lab CBC , INR , s creat , electrolytes , ABG , CRP
Soft tissue Ultrasound and duplex
4 Managment plan
Prepare the pt for incision and drainage
Then asses the graft if it’s liable for repair or not according to infection in the field
if not graft excision will be the appropriate solution
Give Antibiotics according to culture and sensitivity
Given the findings from CT scan and clinical signs, I believe considering graft extraction is appropriate with this scenario
Good assessment
Thanks
Assessment plan
ABCDE
Securing the air way and oxygenation with iv line for cautious fluid resuscitation as ptn is on RHD and ask for labs with ABO groupind and matching cbc inr kft vbg electrolytes
History
Relevant regarding the AVG and any previous history of bleeding from the graft or general history of another source of septic focus along with history of medications specially anti platelets or anti coagulant
Examination
Inspection if the swelling is pulsating for pseudo aneurysm or any skin infection active or contained bleeding
Palpation of distal radial and ulnar pulsations together with signs of infection flactuation for abscess pulsating mass or thrill of ruptured aneurysm or transmitted for hematoma
Auscultation for biruet
Initial Management plan
ABCDE
Apply compression over the sawelling if there is bleeding or signs of anastomosis disruption
Prepare the patient for the OR urgently
Investigation plan
Labs as mentioned
Imaging duplex us on the graft and site of swelling to detect blood flow and the distal run off
ECG
Definitive ttt
Surgical exploration control of brachial artery proximal and distal exploration on venous side of the graft
Evacuation of the swelling with sample for C/S
Removal of the infected graft with c/s
Good irrigation and cleaning of the field
Repair or ligation of the artery and vein according to the distal circulation condition
Broad spectrum antibiotics analgesics
Securing another dialysis access for the patient as mahooker or permicath
Brilliant answer, very methodical and good insight
Well done
Based on the history that she has an AV graft for hemodialysis in. Her lt hand and by examination there is swelling , redness and tenderness with systemic manifestation of fever , tachycardia and hypotension . There is a provisional diagnosis of graft infection . I will start assessment by asking full labs for the patient as CBC. LFT .ABG , ESR, CRP and I will do ECG , I will ask for nephrological consultation as the patient may need an urgent dialysis session
My initial management plan will be urgent admission and I will start embperical course of IV antibiotics till the patient is prepared for intervention
I will ask for Arterial and venous duplex us of LT upper limb to diagnose if there is any collection at the swelling site and it,s relation to graft and blood vessels also X RAY. Of upper limb may demonstrate any gases in soft tissue
After confirmation of collection around graft with gases and high WBCs and CRP I will proceed for graft excision
Good answer, well done
Assessment Plan
Initial Management Plan
Investigation Plan
Management Plan Based on CTA Findings and Lab Results
Important Considerations:
Very thorough and detailed answer , very good methodical approach
I would just consider reconstruction if there is risk of limb schema but would avoid access reconstruction in same setting to avoid risk of 2ry bleeding and ongoing bacteremia
Thanks
_Patient needs urgent hospital admission, IV fluids resuscitation and IV antibiotics.
Full lab tests, ECG, ABG and monitoring of potassium for possibility of hemodialysis session. A cade of infected AV graft for preparation its extraction.
Investigations:
Duplex ultrasound of left arm… for measuring amount of collection and assessment of vascularity.
Management plan:
Urgent graft extraction and debridment of necrotic tissues.
Send the graft for culture and sensitivity tests.
Well done , very good approach and management plan
Case of infected avf
Admission resucitation IV ab
Full lab assessment cbc urea creat Na k blood gases for assessment for needs for urgent dialysis
Preparation for graft extraction
What would be your investigation plan
Duplex us or superficial US is good informative tool for graft infection
The CTA you have done shows collection around the graft with gas and WCC is 21,000 and CRP 284
What would be your management plan
Toxaemic PT needs urgent graft extraction+surgical debridement of infected Wound
Well done, very good approach and management