Presentation on theme: "Cannulation of the Arteriovenous Fistula (AVF)"— Presentation transcript:
1 Cannulation of the Arteriovenous Fistula (AVF) Activity Chair:Lawrence M. Spergel, MD, FACS Clinical Chair, Fistula First National Breakthrough Initiative San Francisco, CaliforniaAuthors:Lynda K. Ball, RN, BSN, CNN Quality Improvement Director Northwest Renal Network Seattle, WashingtonDeborah Brouwer, RN, CNNDirector, Therapeutic & Clinical ProgramsRenal Solutions, Inc.Warrendale, Pennsylvania
2 OverviewCannulation of the Arteriovenous Fistula is designed to help you:Increase understanding of AV fistulasIncrease knowledge of assessment, cannulation, and protection of new and mature fistulasTroubleshoot problems during cannulation and dialysisCommunicate effectively with care team membersEncourage your healthcare team to develop a “New AVF Cannulation Protocol”
3 Overview (cont’d) Assessment of the New AVF for Maturity Protocol for New AVF CannulationCannulation Site Selection and PreparationCannulation TechniquesSelf-CannulationComplications
4 FactWhen Fistula First was initiated in early 2003, it was reported that 80% of prevalent hemodialysis patients in Europe and only 30% of prevalent hemodialysis patients in the United States used an AVF.Fistula First, National Vascular Access Improvement Initiative. Available at: Accessed January 11, 2007.
5 Risks Associated with Poor Cannulation & Improper Care of Fistula Loss of the fistulaFurther hospitalizationCreation of temporary access measuresInconvenienceDisruption of regular treatment regimenHigher treatment costs
6 Mature Arteriovenous Fistula --Photo courtesy of J. Rowland
8 Catheter Used for Dialysis Photo courtesy of J. Rowland
9 Benefits of Arteriovenous Fistula (AVF) Lowest rate of failures and complicationsLongevityLowest costsMerrill D, et al. Dial Transplant. 2005;34:
10 Cannulating a FistulaThe formal description of the process of inserting needles into a vascular accessGraphic courtesy of Medisystems HemoDYNAMIC Devices™
11 Program Overview The new AV fistula: The mature AV fistula: How to assess for:MaturityComplicationsCannulation sitesCorrect way to cannulate itThe mature AV fistula:How to assessHow to select cannulation siteHow to prepare cannulation siteHow to cannulate site using site rotation and the buttonhole technique
14 Fistula MaturationDefinition: Process by which a fistula becomes suitable for cannulation (ie, develops adequate flow, wall thickness, and diameter)Rule of 6’s: In general, a mature fistula should:Be a minimum of 6 mm in diameter with discernible margins when a tourniquet is in placeBe less than 6 mm deepHave a blood flow greater than 600 mL/minBe evaluated for nonmaturation 4–6 weeks after surgical creation if it does not meet the above criteriaNational Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.
15 Clinical Clarification The fistula should be examined regularly following surgery. At 4 weeks post surgery, the fistula should be evaluated specifically for nonmaturation.
16 During AVF Maturation Process Look, listen, and feel the new AVF at every dialysis treatmentAfter the scar heals, begin assessing AVF using a “gentle” tourniquet placed high in the axilla areaInstruct patient to start access exercises after healing (check with surgeon first)Document patient education as well as condition and maturation of the AVF
17 FactExperienced dialysis nurses have an 80% success rate for identifying fistula maturity.Robbin ML, et al. Radiology. 2002;225:59-64.
18 Maturing Fistula Vessel diameter must be 4–6 mm Vessel walls should toughen and be firm to the touchThere should be no prominent collateral veins
20 Clinical Clarification Several studies suggest that performing access exercises after surgery may contribute to the development of the fistula.1-3 However, it is important to note that exercise alone will not turn a poor fistula into a good, functional fistula.1. Rus RR, et al. Hemodialysis Int. 2005;9:2. Leaf DA, et al. Am J Med Sci. 2003;325:3. Oder TF, et al. ASAIO J. 2003;48:
21 During Maturation Feel for strong thrill at arterial anastomosis Listen for continuous low-pitched bruitDocument fistula maturation, patient education
22 During Physical Examination Assess AVF for complicationsThrombosisStenosisInfectionSteal syndromeAneurysmsSelect cannulation sites
23 Is This New AVF Mature and Ready for Cannulation? Photo courtesy of D. Brouwer
24 Is This AVF Mature and Ready for the Initial Cannulation? Vein looks large enoughVein feels prominent and straightVein has a strong thrill and good bruitPhysician orderAll of the aboveANSWER:(All of the above)
25 Fistula MaturationWhat diagnostic tools or techniques can be used to determine if an AVF is ready for cannulation?Can the same tools or techniques be used to select the cannulation sites?
26 Diagnostic Tools/Techniques to Determine If an AVF Is Ready Duplex Doppler studyPhysical exam by the:NephrologistNephrology nurseSurgeonAngiogram (fistulogram)
27 Best Tool/Technique? Physical Exam! Look, Listen, and Feel Use Your: EyesEarsFingertips
28 Maturing Fistula Physical Exam Firm, no longer mushyVessel wall thickeningVessel diameter enlargement (to 4–6 mm)Absence of prominent collateral veinsIf in doubt, “Just Say No”
30 Look for Complications Changes in AccessRednessDrainage InfectionAbscessCannulation sitesAneurysmsExtremitySkin colorEdemaSmall blue or purple veinsHematomaBruisingDistal Areas of Access ExtremityHands/Feet:ColdPainful Steal Numb syndromeFingers/Toes:DiscoloredCentral or outflow vein stenosis
31 Clinical Clarification Thrombosis represents the loss of the access. Stenosis, infection, steal syndrome, and aneurysms need to be addressed to prevent thrombosis and the resultant loss of the access.
32 Stenosis Frequent cause of early fistula failure Juxta-anastomotic stenosis most commonPhoto courtesy of L. Spergel, MD
33 Juxta-Anastomotic Stenoses Most common AVF stenosisVein segment immediately above the arterial anastomosisStenosis also may be present in arteryCaused by? Trauma to segment of vein mobilized and manipulated by the surgeon in creating the AVFBeathard GA. A Multidisciplinary Approach for Hemodialysis Access. New York, NY; 2002:111–118.Beathard GA. Semin Dial. 1998;11:231–236.
34 Observe Access Extremity for Stenosis Before the patient has needles insertedMake a fist with access arm dependent; observe vein fillingRaise access arm; entire AVF should flatten/ collapse if no stenosis/obstructionIf a segment of the AVF has not collapsed, stenosis is located at junction between collapsed and noncollapsed segmentInstruct patient to perform this at home
35 Infection Lower rate with AVF compared with other access types1,2 Staphylococcus aureus the most common pathogen2Patients and dialysis team personnel have high rates of Staphylococcus on skin3Handwashing before, after, and between patients is critical41. National Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.2. Dialysis Outcomes and Practice Patterns Study (DOPPS) Guidelines. Available at:3. Kirmani N, et al. Arch Intern Med. 1978;138:4. Boyce JM, Pittet D. MMWR 2002;51(RR16):1-44.
36 Steal Syndrome Shortage of blood to hand Rare but can be serious Regularly evaluate sensory-motor changes to hand and condition of skin, especially in diabetic patients
38 Signs and Symptoms of Complications Differences in extremitiesEdema or changes in skin color = stenosis or infectionAccessRedness, drainage, abscess = infectionAneurysmsAccess extremitiesSmall, blue/purple veins = stenosisDiscolored fingers = steal syndrome
39 Signs and Symptoms of Complications (cont’d) Temperature ChangesWarmth of extremity = infectionColdness of extremity may = steal syndrome
40 Thrill for Stenosis Abrupt change or loss Pulse-like Narrowing of vein = stenosis
41 Feel for Cannulation Sites Superficial, straight vein sectionAdequate and consistent vein diameter
42 Palpation Temperature Change Thrill Warmth = possible infection Cold = decreased blood supplyThrillPalpation can be started at the anastomosisThrill diminishes evenly along access lengthChange can be felt at the site of a stenosis; becomes “pulse-like” at the site of a stenosisStenosis may also be identified as a narrowed area
43 Palpation (cont’d) Feel for Size, Depth, Diameter, and Straightness of AVFFeel the entire AVF from arterial anastomosis all the way up the veinEvaluate for possible cannulation sites = superficial, straight vein section with adequate and consistent vein diameter
44 Auscultation Listen for the Nature of the Bruit Photo courtesy of J. Holland
45 Auscultation (cont’d) Listen for BruitListen to entire access every treatmentNote changes in sound characteristics (bruit):A well-functioning fistula should have a continuous, machinery-like bruit on auscultationAn obstructed (stenotic) fistula may have a discontinuous and pulse-like bruit rather than a continuous one—and also may be louder and high-pitched or “whistling”Louder at stenosis than at anastomosis
46 Requirements for Cannulation Physician orderExperienced, qualified staff personTourniquet
47 Post-Op Follow-upCommunicate assessment findings with access team, including surgeonCheck maturity progress every sessionAssure evaluation by surgeon 4 weeks post-opIntervene if there is no progress at 4 weeks or AVF is not mature and ready for cannulation at 6–8 weeks
49 Protocol for New AVF Cannulation Define successful cannulationCannulation guidelinesNew AVFMature AVFUnsuccessful cannulationsDetailed instructions for complications
50 Successful First Cannulation of a New AVF A “New AVF Cannulation Protocol” should be developed by the entire healthcare team, including access surgeon and interventional nephrologist/radiologistProtocol should provide:Clear instructions for the initial cannulationSubsequent cannulationsInterventions for complications
51 Cannulation of New Fistula Policy & Procedure See FistulaFirst.org for entire Policy & Procedure.National Vascular Access Improvement Initiative Web site. Available at: Accessed April 21, 2006.
52 Implementing a Unit-Specific Protocol for “New AVF Cannulation” Define:Successful cannulationDocumentation guidelines for all cannulation proceduresUnsuccessful cannulationDetail instructions to follow for any anticipated complications for both staff and patientsExample: If an infiltration occurs on first attempt, should a second attempt be made… and when?
53 Basic Requirements for Cannulation Must have:Physician’s order to cannulateExperienced, qualified staff person who is successful with new fistula cannulationsUse of a tourniquet or some form of vessel-engorgement technique (eg, staff or patient compressing the vein)National Vascular Access Improvement Initiative Web site. Available at: Accessed April 21, 2006.
54 Preliminary Considerations Reduce the patient’s fear of the initial cannulationWords alone can either cause or reduce fear, so choose your words wisely! (Don’t use words like “stick” or “puncture.”)May need to adjust dialysis time to avoid rushing by the staff (eg, midweek or midshift treatments might be best)
55 Preliminary Considerations (cont’d) Ask physician if heparin dose should be modifiedUse 17-gauge needles initiallyUse saline-filled fistula needles with syringes attached (optional)Use a tourniquet
56 Needle SelectionIf patient has a catheter, use 1 lumen of the catheter and 1 needle in the fistulaWhen using 1 needle for first cannulation of the AVF, which needle should you use?Arterial needle?Venous needle?ANSWER:(Arterial needle)
57 Arterial Needle: First Use Arterial needle in the AVF, at least for the first useRationale:If an infiltration occurs, blood is not being forced back into the needle via the blood pump = smaller hematomaAlso, permits pre–pump arterial pressure (AP) monitoring,which will help to determine if the fistula has a good accessflow. The pre–pump AP should be ≤ –250 mm Hg at a blood flow rate (BFR) with a 17-gauge needle. Excessively negative pre–pump AP = poor AVF inflowThus, lower risk of complications with arterial needle used as the first needleNational Vascular Access Improvement Initiative Web site. Available at: Accessed April 21, 2006.
58 Recommended Use of a Cannulator Rating System Cannulation knowledge and skill requirements integrated into a competency-based assessment template for use in staff learning and evaluationEnhance continuing education and training of dialysis staffImprove patient outcomes through 2 principal means:Reduced hospitalizationsFewer access complications
59 Cannulator Rating System Level 1: New employee with no experienceLevel 2: New employee with experienceLevel 3: Current employee improving competencyLevel 4: Most experienced, competent cannulator
60 Preliminary Steps Reduce patient fears Educate patients Choose your words carefullyAdjust dialysis scheduleEducate patientsWhat they may feel during procedureReport symptoms of complicationsConsult nephrologist concerning heparin dose modification when initiating AVF use
61 Needle Selection Arterial needle for new AVF Rationale Smaller hematoma if infiltration occursArterial needle permits pre-pump AP monitoring to evaluate blood flowPre-pump AP ≤ –250 mm Hg at 200 mL/min (BFR) with a 17-gauge needleNational Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.
62 Clinical Clarification Pre-pump arterial pressure:is the pressure exerted by the blood pump on the blood in the tubing segment between the access and the blood pump (pre-pump segment)is negative because the pump creates a vacuum that “pulls” blood from the accessshould be monitored at all times and not be permitted to become more negative than –250
63 Determine Direction of Access Flow Check Direction of Flow by:LookingInspect access for incisions/location of anastomosisFeelingPalpate accessGently compress access midpointArterial inflow will “pulse with flow”Venous outflow will have diminished or no pulseListeningAuscultate accessArterial inflow will have pulsatile soundVenous outflow will have minimal or no sound
64 Needle Gauge17-gauge needle is strongly recommended for initial cannulationA fistula may appear and feel ready to cannulate, but the vessel wall may still be fragile and unable to tolerate the needle punctureThe smaller needle gauge helps to decrease injury to the vessel and prevents a large infiltration, hematoma, compression of the vessel, and possible clotting of the AVF should any cannulation complication occur (ie, infiltration)
65 Adequacy of Needle Length Standard AVF needles are 1″ long and are routinely inserted into the needle hubShallow new AVFs may benefit from shorter needlesShorter, 3/5″ AVF needles may advance fully into the shallow fistula
66 Adequacy of Needle Gauge Compare needle with fistulaUse 3/5″ needle for shallow AVF
67 Matching Needle Gauge to the Prescribed BFR Smaller needle gauge requires lower blood flow rates (BFRs)Needle gauge may be a specific physician orderGeneral needle gauge guidelines and maximum BFR with the pre–pump AP ≤ –200 to –250 mm Hg17-gauge needle = 200–250 BFR16-gauge needle = 250–350 BFR15-gauge needle = 350–450 BFR14-gauge needle = > 450 BFRMust monitor pre–pump AP to prevent excessive negative pressure from the blood pump drawing on the vascular access. Pre–pump AP should be ≤ –250 mm Hg for all needle gauges and BFRs*Follow your unit-specific nursing policy and procedure forspecific needle gauge and maximum BFR.
68 Non–back-eye needle—for venous use only Use Back-Eye NeedlesNon–back-eye needle—for venous use onlyBack-eye opening allows blood intake from both sides of the needle; can be used as arterial or venous needleArterial needleVenous needle
69 both the bevel and back-eye Back-Eye Needle FlowAllows blood toenter or exit fromboth the bevel and back-eye
70 Determining Direction of Access Flow Locate anastomosisPalpateArterial inflow “pulses with flow”Venous outflow = diminished or no pulseAuscultateArterial inflow = pulsatile soundVenous outflow = minimal or no sound
71 Adequacy of Needle Gauge Once the AVF is established, to ensure the needle gauge used is correct, perform the following check:Examine vessel sizeHow does it compare to needle size?Compare size with and without tourniquetDetermine if the vessel diameter is adequate to accept the prescribed needle gauge
72 Catheters: Flushing and Heparinization If a catheter is in place:Consider any required adjustments to the heparin dose and timing for systemic heparinization (bolus, hourly, and end-time of hourly infusion) to prevent excess bleedingConsider the procedure for flushing and heparin locking the catheter lumens pre- and post-hemodialysis treatment to prevent excessive bleeding
73 Patient EducationInform patients of what they may feel during the initial cannulation procedureAsk patients to report immediately any symptoms of any procedure complications (eg, pain, bleeding)Consider developing a teaching handout for patients’ first cannulation experience (address pre- and post-first cannulation concerns)
74 Needle DirectionAlways cannulate the venous needle with the direction of the blood flowAlways cannulate the arterial needle cannulation toward the blood inflow or with the blood outflow
75 Needle Direction Photo courtesy of D. Brouwer Venous needle directed back toward the heartArterial needle directed toward thearterial anastomosis (retrograde)Photo courtesy of D. Brouwer
76 Needle Direction Photo courtesy of D. Brouwer Venous needle directed back toward the heartArterial needle also directedback toward the heart (antegrade)Photo courtesy of D. Brouwer
77 New AVF Cannulation Protocol Always use a tourniquet, regardless of the size or appearance of vesselUse of the tourniquet helps to engorge, visualize, palpate, and stabilize the AVFUse 20–35° angle for needle insertion for an AVF
78 Consider Optional Use of “Wet” Needles Prime the fistula needle with normal saline solution (NSS) and leave a 10-cc syringe attached to the needleCheck/aspirate for blood returnThen flush carefully with NSS to check for any evidence of infiltration (with and without the tourniquet constricting the AVF)Rationale: Since blood return alone is not enough to show good needle placement, flushing with NSS will be less traumatic than flushing with blood, should an infiltration occurNational Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.
80 When to Advance to 2 Needles Only after the arterial needle functions without:Infiltration or hematomaCannulation difficultiesAccess blood flow problemsExcessively negative pre–pump arterial pressuresBleeding around the needle during dialysisProlonged bleeding post-dialysisAt least 3–6 treatments tolerating one 17-gauge needle for arterial inflow
81 Clinical Clarification Whether a clinician advances to 2 needles after 3 or 6 successful cannulations depends on his or her experience, clinical judgment, and the patient’s needs.
82 Advancing Needle Gauge Use same criteriaNeedle gauge in physician’s orderMatch the needle gauge to hemodialysis blood flow rate
83 When to Advance Needle Gauge When both fistula needles function for at least 3–6 hemodialysis treatments at prescribed blood flow rate (BFR) and needle gauge without:Infiltration or hematomaCannulation difficultiesAccess blood flow problemsExcessively negative pre–pump arterial pressuresExcessive venous pressuresBleeding around the needle during dialysisProlonged post-dialysis bleeding
84 Match Needle Gauge to Blood Flow Rate (BFR) Maximum BFR17-gauge< 300 mL/min16-gaugemL/min15-gauge350–450 mL/min14-gauge> 450 mL/min
85 Needle Gauge Smaller needle gauge requires lower BFRs Needle gauge may be a specific physician orderGeneral needle gauge guidelines and maximum BFR with the pre–pump AP ≤ –200 to –250 mm Hg17-gauge needle = 200–250 BFR16-gauge needle = 250–350 BFR15-gauge needle = 350–450 BFR14-gauge needle = > 450 BFRMust monitor pre–pump AP to prevent excessive negative pressure from the blood pump from drawing on the vascular access. Pre–pump AP should be ≤ –250 mm Hg for all needle gauges and BFRs*Follow your unit-specific nursing policy and procedure forspecific needle gauge and maximum BFR.
86 Arterial and Venous Pressure Monitoring and Limits A must, especially for a new fistulaPre–pump arterial pressure (AP) must be less negative than –250 mm HgVenous pressure (VP) should not exceed the BFR with a 17-gauge needleExample: At BFR of 200 mL/min, VP should not exceed 200 mm HgFollow unit-specific processes and procedures for needle gauge and maximum BFRNational Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.
87 Understanding Pre-pump APs Measures pull exerted on needle and fistula by blood pumpAP exceeding –250 mm Hg– Significant drop in delivered blood flow– HemolysisNational Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.
88 Pre-pump Arterial Monitoring Normal Range*Effect on Delivered Blood Flow•Refill rateStroke volumeActual delivered QbURR / Kt/V outcomes_+-180mmHg•Negative PressureCreated by pump strokeAffected by accessAffected by needle gaugeAffected by needle positionAffected by tubing450mlActual 450ml*Shows the effect of a normal pre-pump arterial pressure on delivered flow
89 Pre-pump Arterial Monitoring Excessively negative pre-pump arterialpressure*_+-280mmHg450mlActual 380ml*Shows the effect of an excessively negative pre-pump arterial pressure on delivered flow (ie, reduction)
90 WARNING!Do not disarm the AP monitor, and always check to be sure that the pressure transducer is not wet and is functioning.Fistula First, National Vascular Access Improvement Initiative. Available at: Accessed January 11, 2007.
91 Clinical Clarification Anything that makes it difficult for the pump to “pull” blood from the access will make the pre-pump AP excessively negative.
92 What Causes the Pre–Pump AP to Be Too Negative? Increasingly negative pre–pump AP indicates insufficient blood inflow for the blood pump BFRExcessively negative pre–pump AP can be caused by anything that restricts arterial inflow to the blood pump:Inadequate blood flow from the accessNeedle gauge too small for prescribed BFR (ie, needle gauge “mismatch”)Obstructed needleObstructed or kinked line (a kinked arterial blood line can cause life-threatening hemolysis)
93 Actual Blood Flow Rate Decreases as Pre–Pump AP Becomes More Negative Actual BFRVarying pre–pump arterial pressuresBFR pump settingDepner TA, et al. ASAIO Trans. 1990;36:M456–M459.
94 Clinical Clarification The danger of excessively negative pre-pump AP is that it causes a reduction in actual delivered blood flow, and also can cause hemolysis (destruction of red blood cells).
95 What Actions Should Be Taken if Pre–Pump AP Is Too Negative? Increasingly negative pre–pump AP indicates insufficient blood inflow to meet the blood pump BFR demandLarger-gauge needles may be needed for higher BFR settingsCheck to make sure that needle is not obstructed or that blood line is not kinkedBlood pump speed as prescribed may not be attainable and may need to be reduced if/until cause is identified and remediedNotify physician that access flow is not sufficientIf pre–pump negative pressure is extreme (≥ –300 mm Hg), or rises rapidly during dialysis, act quickly; reduce blood pump speed until pressure falls into acceptable range, check blood lines for kink, and notify physician
96 Catheter RemovalOnce the patient has had 6 successful treatments with the AVF, the registered nurse (RN) should obtain an order to have the catheter removedSuccessful = getting 2 needles in, no infiltrations, and reaching the prescribed BFR throughout the treatment for 6 treatments
97 Clinical Clarification It is important to actively engage your critical thinking skills when deciding on the appropriate timing of catheter removal.
98 New AVF Cannulation: Additional Points On removal of needles, for hemostasis:Use 2-finger compressionNever use clampsHold sites for 10 minutes—no peeking
99 Education for Patients Check fistula daily for a thrill and bruitCheck for signs and symptoms of infection or other complicationsWrite instructions for infiltrations
100 Call the Nephrologist/Physician Thrill is undetectablePatient becomes feverish, dehydrated, or experiences low blood pressure
102 “Sleeves Up” ExamAssessment of mature forearm fistulas (as well as forearm grafts) should include a monthly “sleeves up” exam of the upper arm, to identify mature outflow veins of the forearm AVF or AVG that might be potential candidates for a future upper-arm AVF (see “Sleeves Up” protocol in Change Concept #6 at FistulaFirst.org)If an upper-arm vein appears to be suitable for a future AVF, make note in chart and notify nephrologist and surgeon that the upper-arm vein is available as a new AVF should the existing AVF or AVG fail.Spergel LS. Protocol. National Vascular Access Improvement Initiative Web site. Available at: Accessed June 26, 2006.
103 “Sleeves Up” Exam…Outflow vein (cephalic v.) of failing forearm AV graft is suitable for conversion to AVFPhoto courtesy of L. Spergel, MD
105 Physical Assessment Assess AVF before every cannulation Compare arms for changes in skin color, circulation, integrityInspectAccess extremity for central or outflow vein stenosisDistal areas of extremity for steal syndromeAccess for vessel size, cannulation areas, infection, aneurysmsPalpateTemperature change may mean infection or stenosisChange in thrill may mean stenosisAuscultateListen to entire access for changes in bruit that indicate stenosis
106 Identify Ideal Segment of AVF Look and feel for a straight segment of AVFSegment must be as long as the needle length (ie, 1″ minimum)Stay at least 1.5″ from the AVF anastomosisThe arterial and venous needles need to be 1″ to 1.5″ apartAvoid curves, flat spots, and aneurysms to prevent complications
107 Site PreparationDialysis patients have more Staphylococcus spp (SA and MRSA) on their skin and in their nares (nose) than the general populationDialysis staff can also have a higher rate of staph carriageCommon route of transmission of staph is from the nose to the skin to the vascular access = infectionSA: Staphylococcus aureusMRSA: methicillin-resistant S aureusKirmani E, et al. Arch Intern Med. 1978;138:1657–1659.Boelaert JR. J Chemother. 1994;6:19–27.Yu VL, et al. N Engl J Med. 1986;315:91–96.
108 Skin PreparationIf possible, the patient should wash the access with antibacterial soap before coming to the chairStaph is the leading cause of infection in dialysis patientsPhoto courtesy of L. BallBoyce JM, Pittet D. Guidelines for hand hygiene in health-care settings. Available at: Accessed April 28, 2006.
109 Skin Preparation (cont’d) Proper needle-site preparation by both the patient and staff reduces infection ratesOnce the skin site is properly cleansed, the skin should not be touched with bare hands or gloved handsIf touched, re-prep the skinAll site selection should be done prior to the final skin preparation
110 Applying Chlorhexidine Gluconate Wet insertion site for 30 secAllow to air-dry for ≈30 secDo not blot or wipe
111 Applying Sodium Hypochlorite Saturate sterile gauze padClean sites with circular motionWait 2 minutes before proceeding
112 Proper Cleansing Technique Proper needle-site preparation reduces infection ratesStart where you are going to place the needle (the black dot) and cleanse in a circular, outward motionDo not touch skin after cleansing area
113 Says Who?Locate, inspect and palpate the needle cannulation sites prior to skin preparation. Repeat prep if the skin is touched by the patient or staff once the prep has been applied, but the cannulation not completed.Wash access site using an antibacterial soap or scrub and water.Cleanse the skin by applying 2% chlorhexidine gluconate/70% isopropyl alcohol and/or 10% povidone iodine as per manufacturer’s instructions for use.Notes:2% chlorhexidine gluconate/70% isopropyl alcohol antiseptic has a rapid (30 s) and persistent (up to 48 hr) antimicrobial activity on the skin. Apply solution using back and forth friction scrub for 30 seconds. Allow area to dry. Do not blot the solution.KDOQI Says:For all vascular accesses, aseptic technique should be used for all cannulation and catheter accession procedures (evidence)National Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1–S322.
114 Anesthetic Options for Pain Control Needle fear and pain with needle insertion are very real issues for many hemodialysis patientsVarious pain-control options can be utilized to make the cannulation procedure less stressful for patients
115 Intradermal Anesthetics Lidocaine injected under the skin and above the vesselAdvantage: Numbs the area prior to the cannulation procedureDisadvantages: Can cause scarring, vasoconstriction, keloid formation, burning with injection, and poses a needle-stick risk
116 Topical SpraysTopical sprays (ethyl chloride) can be used to numb the skin sitesAdvantage: Noninvasive method of numbing the skinDisadvantages: Nonsterile, requires patient-specific bottle to prevent cross-contamination, may discolor or damage skin with long-term use, flammable contents in bottleMethod: Spray arterial site, prep skin, then insert needle immediately; repeat for venous site
117 Topical CreamsTopical creams contain lidocaine and may be applied by the patient at least 1 hour prior to treatmentAdvantage: Provides numbing to a larger cannulation areaDisadvantages: Cost of the medication, causes vasoconstriction, need to educate patient on the amount needed because using too much cream may lead to vasodilatation up to 3 hours into the dialysis treatmentMust wash the skin prior to the application of the cream as well as before prep for needle cannulation
118 Using Topical Creams Wash skin first Apply 1 hour before dialysis Cover with plastic wrapPrior to cannulation, remove cream, wash/prep skin
119 Tourniquet Use Tourniquet required for all cannulations Apply tightly enough to engorge vessel
121 Why Offer Self-Cannulation? Benefits for patients:Less painfulLess likely to promote fear and anxietyLess stressfulGreater feeling of controlInspires confidenceAccess may last longerAlternative hemodialysis options
122 What Are Patients Saying? “You never know the qualifications of the person inserting the needles, and you know your own.”“You may want to consider learning how to insert your own needles. A bunch of us have, and you can’t imagine the sense of independence and relief that accompanies this self-care task.”Quotes from the Kidney School™. Available at: school.org. Accessed May 1, 2006.
123 What Are Professionals Saying? Centers for Medicare & Medicaid (CMS) Fistula First Change Package #8: Cannulation Training for AVFsFacility offers option of self-cannulation to patients who are interested and ableAmerican Nephrology Nurses’ Association (ANNA) Position Statement: Vascular Access for HemodialysisEducation in self-cannulation should be offered to patients judged to have the ability and the access placement that enable them to do so
124 What Are Professionals Saying? (cont’d) Food and Drug Administration (FDA): Guidance for Nocturnal Home Hemodialysis (NHHD) DevicesTraining in self-cannulation should be considered in NHHDMEI Kidney School™“Putting in your own needles is the best way to have your dialysis lifeline last as long as possible.”Vascular Access SocietyThe buttonhole technique is recommended for self-cannulation
125 Plan Your Training Provide a quiet, calm environment Allow the patient to ask questionsHave the patient practice:Getting the “feel of the needles” with apractice armDetermining angle of insertionAssessing their accessPutting on and taking off the tourniquet
127 Prepare the NeedleWash hands and access with soap and water; dry thoroughlyUsing sterile technique, draw up 5 cc’s of NSS into each 10-cc syringe; attach syringe to the end of the needle tubing; fill needle tubing with saline by pressing the plunger until a little saline drips out of the end of the needle cap; close the clamp on the needle tubing
128 Assess the Access and Select the Site Complete the physical assessment of the access:Feel for the thrillListen for a bruitCheck for infection, bruising, hematoma, prior needle-insertion sites, curves, flat spots, stenosis, aneurysms, diameter, and depthSelect sites for cannulation:Site rotation—stay 1.5″ away from anastomosis, keep 1–1.5″ between needle sitesButtonhole—locate prior scab sites
129 Clean the Site and Apply a Tourniquet Cut all the tape you will need before cannulatingApply antibacterial cleaning solution to both chosen sites according to the manufacturer’s directions; allow to dry before cannulating. (Exception: If using alcohol, apply to one site and cannulate, then apply to second site and cannulate; it has a short-acting time span and needs to be cannulated immediately after cleansing)Apply the tourniquet on the upper arm near axilla to 1) stabilize fistula (to keep it from rolling); 2) engorge the fistula (to see it better); 3) feel the fistula better (to determine correct angle of entry)All AVFs must have a tourniquet
130 How to Apply a Tourniquet When using a tourniquet with VelcroTM: Wrap tourniquet around the upper arm, pull tight, and secure with the VelcroTM tabWhen using a tourniquet without VelcroTM: Wrap tourniquet around the upper arm so the tails are even; pull both ends straight up with the nonaccess hand; twist tourniquet ends twice, close to the skin, and apply a scissor clamp close to the skinPut on clean gloves
131 Prepare the Arterial Needle Pick up the arterial needle:If color-coated, it will have a red clamp; if not, make sure it has a back-eyeWith your thumb and forefinger, grasp the needle wings together so the opening of the needle (bevel) is facing upRemove the needle cap, being careful not to touch anything with it (maintain sterility)If the needle becomes contaminated, dispose of it in the sharps container and get a new sterile needle
132 Insert the Arterial Needle Using the side of your hand that is holding the needle, pull the skin back toward you; this will:Tighten the skin to allow needle to go in more smoothlyCompress nerves, thus blocking your pain response for 20 secondsBased on the depth of the access when you completed your assessment, determine the angle of insertion for your needle (typically between 20° and 35°)Put the needle directly over the access at your chosen angle, and push the needle into the skin until you see blood entering the needle tubing (flashback)
133 Insert the Arterial Needle (cont’d) Lower your angle of insertion and advance the needle into the access until it is completely under the skinNote: If the blood stops moving in the needle tubing or you feel resistance, STOPOnce the needle is in the access, place a piece of 1″ paper tape over the wingsThis will keep needle from moving around in the accessOpen the clamp on the needle tubing and pull blood into the syringe, then put it back in your arm, being careful not to push any air into the tubing
134 Insert the Venous Needle Clamp the lineApply a ½″ piece of plastic tape, sticky side up, under the needle just below the wings; cross the tape over the wings in a “V” shape (chevron) to prevent the needle from falling out of your arm during dialysisPick up the venous needle and repeat the needle-insertion processOnce the second chevron is in place, make sure both needle-tubing clamps are closed and remove the arterial needle syringe; attach it to the machine’s arterial blood tubing
135 Operate the Blood PumpTurn on the blood pump to 150–200 mL/min and allow blood to flow through the extracorporeal circuit until it reaches the venous drip chamberTurn the blood pump off and connect the venous blood tubing to the venous needle tubingUnclamp the venous blood needle tubing and turn the blood pump to 200 mL/min
136 Remove the Needles After the blood is returned, clamp both needles Obtain a blood pressure, then place a Chux pad under the accessOpen gauze packageCarefully remove chevrons from both needlesCarefully take the tape off the venous needle only
137 Remove the Needles (cont’d) Take one piece of the gauze, fold, and place over the needle site without applying any pressureHave staff or helper remove the needle, then apply pressure to the needle site until bleeding stopsDispose of the needle in a sharps containerRemove arterial needle as above and apply Band-Aids® to each site; remove after 2–4 hours
138 Helpful Tips The sooner self-cannulation starts, the better Some patients lay the pinky finger of their needle-inserting hand alongside the fistula to provide leverage for pushing and to keep the access from moving
140 BleedingBleeding during treatment (oozing around needle or infiltration) = fragile vessel wall or back wall penetration; don’t flip the needlesBleeding post–needle removal = fragile vessel wall or needle trauma or inadequate pressure at puncture sitesReview needle-removal technique. Improper pressure with needle withdrawal = vessel damageA pattern of prolonged bleeding post–needle removal may indicate stenosis or clotting disorder. Evaluate bleeding after 20 minutesEducate patients about post-treatment hemostasis and what to do at home should the needle site re-bleed
141 Infiltration = Hematoma Photo courtesy of D. Brouwer
142 Prevent Cannulation Infiltrations Don’t flip needleDon’t lift needle in veinFlush with NSS
143 Prevent Postdialysis Infiltrations Apply gauze without pressureRemove needle at insertion angleApply pressure with 2 fingersHold pressure 10–12 minutes
144 Treating Infiltrations Elevate arm above heartIce 20 minutes on/20 minutes off for 24 hoursWarm compresses after 24 hoursLet fistula restSecond infiltration: Notify vascular access teamDon’t use AVF until directed
145 Infiltrations in New AVF Elevate arm above the level of heartWhile protecting the skin over access area with a clean cloth, gently apply:Ice 20 minutes on/20 minutes off for first 24 hoursWarm compresses after 24 hours
146 Infiltrations in New AVF (cont’d) If the fistula infiltrates, let it “rest” until the swelling is resolved (see KDOQI Guidelines)If the fistula infiltrates a second time, the RN should notify the vascular access team, including the surgeon, as soon as possible for interventionDon’t use that AVF until further directedRN: registered nurse
147 How to Prevent Infiltrations Check for flashback and aspirateFlush with NSS to ensure the needle flushes with ease and there are no signs or symptoms of infiltrationSaline causes much less damage and discomfort than blood if an infiltration occurs
148 Post-Cannulation Bruising and Hematoma If bruising or hematoma occurs after dialysis, the surface skin site has sealed but the needle hole in the vessel wall has notUse 2 fingers per site for hemostasisIt is crucial to apply pressure to both the skin and access wall puncture sitesReprinted with permission of L. Ball and the American Nephrology Nurses' Association publisher, Nephrol Nurs J. 2006;33:302.
149 AVF Bleeding Emergency Kit for Dialysis Patients Gauze pads to apply to the bleeding siteTape to apply once the bleeding has stoppedInformation Card:Vascular access type/locationName and phone number of the vascular access surgeon and address of the closest hospital, should the bleeding not stop and further assistance be required
150 Poor Flow May be due to location or position of needle(s) May need to change direction of arterial needleIf poor flow persists after next session despite changing needle locations, refer to surgeon for evaluation and possible treatment optionsNOTE: Use tourniquet for cannulation only!Do not leave in place for entire treatment!!!
151 AneurysmCaused by stenosis as vessel narrowing increases “back pressure,” causing vessel distension and weakening of vessel wallMay also be caused or aggravated by frequent cannulations in the same areaPhoto courtesy of P. Cade
152 Stenosis Most common complication Causes: IV, CVC, PICC lines Surgery to create AVFAneurysmsMay be caused by the back pressure associated with stenosisNeedle-stick injury
153 Types of Stenoses Juxta-anastomotic (most common stenosis in AVF) Central-veinJuxta-anastomotic (most common stenosis in AVF)Mid-accessOutflowCentral vesselOutflowMid-accessInflowForearm AVFGraphic courtesy of L. Ball
154 Central-vein Stenosis Images courtesy of Microvena Corp
155 Distended, Obstructed Left Shoulder Veins Indicative of Central-vein Stenosis Photo courtesy of J. Holland
156 Clues to StenosisClotting of the extracorporeal circuit 2 or more times/monthPersistently swollen access extremityChanges in bruit or thrill (ie, becomes pulse-like)Difficult needle placementBlood squirts out during cannulationElevated venous pressures
157 Clues to Stenosis (cont’d) Excessively negative pre-pump APDecreased blood pump speedsInability to achieve BFRChanges in Kt/V and URRRecirculationProlonged postdialysis bleedingFrequent episodes of access thrombosisKt/V: kidney or dialyzer (treatment time) URR: urea reduction ratioTotal volume of urea
158 Observe Access Extremity for Evidence of Stenosis Perform a physical exam for AVF stenosisPerform before patient has needles insertedHave patient keep access arm dependent and make a fist—observe vein fillingHave patient slowly raise the access arm—the entire AVF should collapse if no stenosis; if entire vein is not flat, indicative of stenosisIf a segment of the AVF has not collapsed, stenosis is located at junction between collapsed and noncollapsed segmentPatient can do this at home
159 Thrombosis Surgical/technical problems Preexisting anatomic lesions (eg, old IV injury)Premature usePoor blood flowHypotensionHypercoagulationFistula compression
160 InfectionAV fistulas have lowest risk of infection of any vascular access type. However…Each pre- and post-treatment exam should include:Checking for signs/symptoms of infection, including:Changes of skin over access areaRednessIncrease in temperatureSwelling, hardnessDrainage from incision, needle sitesTenderness or painPatient complaints without other indications ofMalaiseFever
161 Prevention of Infection General hygienePretreatment washing of access extremityHand washing, before and after cannulationNo scratching, irritation of skin of access extremityPrecannulationAppropriate skin antisepsisSufficient antiseptic-skin contact timeCannulate while antiseptic is wet or dry, as directedCannulationMaintain needle sterilityDo not cannulate through scabs or abraded areas
162 Steal Syndrome/Ischemia Steal syndrome is a constellation of symptoms related to ischemia (inadequate blood supply to the hand) caused by the AVF “stealing” blood away from the extremitySteal causes hypoxia (lack of oxygen) to the tissues of the hand, resulting in severe pain and identified by nail bed discoloration, a cool hand, and a weak or absent pulseNeurological and soft tissue damage to the hand can occur, resulting in mobility limitations (eg, grip strength, dexterity), loss of function, ulcerations, necrosisSteal syndrome/ischemia is estimated to occur in approximately 5% of vascular access patients, mostly those with diabetes and peripheral vascular disease (PVD)
163 Clinical Clarification Steal syndrome is estimated to occur in approximately 5% of vascular access patients, mostly those with diabetes and peripheral vascular disease.Henriksson AE, Bergqvist D. J Vasc Access. 2004;5:62–68.
164 “Claw Hand” Contracture From Steal Syndrome Photo courtesy of J. Holland
165 Steal Syndrome/Ischemia Steal symptoms may improve due to the development of collateral circulationProcedures, such as the DRIL (distal revascularization-interval ligation), can successfully treat steal and ischemiaIndividuals who are at high risk for developing acute steal are:Patients with diabetic neuropathyPatients with PVDHenriksson AE, Bergqvist. J Vasc Access. 2004;5:62–68.
166 Is Steal Syndrome Serious? Steal/ischemia may lead to loss of function and amputation if not recognized and treated quicklyNecrotic tissue cannot be “fixed”—it must be removedSteal/ischemia places patients at risk for infectionInfection increases their risk for hospitalizationHospitalization increases their risk for death!
167 Educational Goals Achieved Understand the importance of AVFUpgrade your knowledge of cannulation techniquesTroubleshoot problemsCommunicate effectively with other members of the patient care team
168 For further information on cannulation and other AVF issues, please visit the official Fistula First Web site at: