Labriola Laura, Crott Ralph, Desmet Christine, Romain Cécile, Jadoul Michel
Division of Nephrology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.
Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium.
Nephrol Dial Transplant. 2024 May 31;39(6):1000-1007. doi: 10.1093/ndt/gfad229.
Buttonhole (BH) cannulation of native arteriovenous fistulas (AVFs) appears to be associated with an increased infectious risk. We previously reported a dramatic increase in the incidence of infectious events (IE) after shift to the BH technique in an in-center hemodialysis unit, which was largely reduced after staff (re)education regarding strict respect of the procedure. We assessed the evolution over the following 12-year period in our center.
In this prospective follow-up of a previous, pre [rope-ladder (RL)]-post (BH) comparison (2001-10), all in-center hemodialysis patients with a native AVF were included from 1 July 2010 to 31 December 2022. Primary and secondary outcomes were IE (unexplained bacteremia due to skin bacteria and/or local AVF infection) and complicated IE (metastatic infection, AVF surgery, death). Overall, the impact of several quality improvement strategies was tested according to the events rate over six periods: Period 1: RL in all; Period 2: switch to BH; Period 3: BH in all, before workshops; Period 4: BH in all, after workshops; Period 5: BH withdrawal in problematic AVFs; Period 6: additional procedural changes.
This extended observation period allowed the addition of 195 180 AVF-days to our previous report. Overall, 381 661 AVF-days (366 AVFs, 345 patients) were analysed. After an increase of the IE rate in 2012, the shift to RL in problematic AVFs during Period 5 did not have a significant impact. The incidence of IE decrease significantly during Period 6 compared with Periods 3, 4 and 5 {incidence rate ratio (IRR) 0.24 [95% confidence interval (CI) 0.09-0.52], P = .0001, IRR 0.22 (95% CI 0.09-0.47), P < .0001 and IRR 0.29 (95% CI 0.11-0.66), P = .001, respectively}, and became eventually for the first time comparable to Period 1 [IRR 0.59 (95% CI 0.21-1.62), P = .27].
The constant observance of reinforced hygiene protocols by trained staff and central coordination succeeded in significantly mitigating the infectious risk associated with buttonhole cannulation.
自体动静脉内瘘（AVF）的纽扣式（BH）穿刺似乎与感染风险增加有关。我们之前报告过，在一家中心血液透析单位，转换为BH技术后感染事件（IE）的发生率急剧上升，在对工作人员进行关于严格遵守该操作的（再）培训后，感染事件大幅减少。我们评估了在接下来的12年里我们中心的情况变化。
在这项对之前前瞻性绳梯式（RL）-纽扣式（BH）对比研究（2001 - 2010年）的随访中，纳入了2010年7月1日至2022年12月31日期间所有在中心接受血液透析且有自体AVF的患者。主要和次要结局分别为IE（由皮肤细菌引起的不明原因菌血症和/或局部AVF感染）和复杂性IE（转移性感染、AVF手术、死亡）。总体而言，根据六个时间段的事件发生率测试了几种质量改进策略的影响：第1阶段：全部采用RL；第2阶段：转换为BH；第3阶段：全部采用BH，在举办研讨会之前；第4阶段：全部采用BH，在举办研讨会之后；第5阶段：对有问题的AVF停止使用BH；第6阶段：额外的程序改变。
这个延长的观察期使我们在之前报告的基础上增加了195180个AVF日。总体而言，分析了381661个AVF日（366个AVF，345名患者）。2012年IE发生率上升后，第5阶段对有问题的AVF转换回RL并没有显著影响。与第3、4和5阶段相比，第6阶段IE的发生率显著下降{发生率比（IRR）分别为0.24 [95%置信区间（CI）0.09 - 0.52]，P = 0.0001；IRR 0.22（95% CI 0.09 - 0.47），P < 0.0001；IRR 0.29（95% CI 0.11 - 0.66），P = 0.001}，最终首次与第1阶段相当[IRR 0.59（95% CI 0.21 - 1.62），P = 0.27]。
经过培训的工作人员持续遵守强化的卫生规程以及中央协调成功地显著降低了与纽扣式穿刺相关的感染风险。
