Colleagues,
What are your methods for achieving hemostasis post sheath removal? I use a nylon suture and I write an order for my hemostasis suture be removed at the next hemodialysis session. It also serves as a reminder to the dialysis unit that this patient had something done to their access; maybe we should read the procedure note and find out if we should do something different.
One of the LDOs has adopted a policy that only allows MDs and Advanced Practitioners to remove sutures in their dialysis units. Nurses and techs have a long history of removing sutures competently. Apparently it is a liability issue.
Manual compression works but is labor intensive and takes time which is not an efficient method in a busy access center with rapid turnover. I can remember a few patients who came back to the access center who started bleeding in the car ride home. I suppose leaving the sutures for one or two weeks until the rounding MD or AP can remove the suture in the dialysis unit is safe but that does not seem ideal. Does anyone use absorbable sutures or skin glue?
Jeff Hoggard
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Posted Tuesday, October 23, 2018
If a bigger sheath is used or high dose anticoagulation/thrombolysis is used during the procedure, the sheath is removed after applying a non-absorbable suture. DaVita and US Renal Care unfortunately has the "No suture removal policy by the staff". The Fresenius staff continues to remove sutures, which appears to be optimal or good patient care.
I usually have the sutures removed the day after the procedure unless the procedure was done on a Friday. At this point, we make the patients belonging to DaVita and USRC to come back (walk-in) to the center next day for the suture removal by the access center staff. In case of inconvenience or transportation issues for the patients, I keep them for about 30 to 45 minutes after the procedure in the access center (depending on the sheath size and anticoagulation) and then discharge the patient after the staff removes the suture. If the patient is from a nursing home, my staff calls the nursing home folks and request the suture removal.
In our home hemodialysis program, we have provided the dialysis staffs with the suture removal kits and they do not have any problem in removing the sutures.
There are thrombosis patches (like Neptune patches, etc.) that can be applied at the sheath insertion sites, but these patches are relatively expensive compared to the Tip-Stops.
Personally, I avoid applying absorbable sutures at the sheath insertion sites, since the dermal part of the suture does not get absorbed and the suture end will end up sticking out with the risk for infection. Moreover, externally applied absorbable sutures will end up leaving nodular scars at these sites due to the inflammatory response if these sutures are forgotten to be removed within few days' time. I also do not use dermabond or steri-strips at these sites, even though it is available in our center for the incision site application.
The "No Suture Removal" policy has become such a nuisance, time-waste and markedly inconvenient for the dialysis patients, whose life is already in turmoil with all the dialysis visit as well as other office visit schedules they after to attend. I hope these dialysis centers will have the courtesy, compassion and thoughtfulness to provide convenient care for these patients, who is providing the revenue for the survival of these centers. When these centers can do complicated and risky dialysis treatments, I am not sure how a simple superficial skin suture removal becomes a heavy burden or a legal risk for these centers ????.