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Cannulation of the Arteriovenous Fistula (AVF)

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1 Cannulation of the Arteriovenous Fistula (AVF)
Activity Chair: Lawrence M. Spergel, MD, FACS Clinical Chair, Fistula First National Breakthrough Initiative San Francisco, California Authors: Lynda K. Ball, RN, BSN, CNN Quality Improvement Director Northwest Renal Network Seattle, Washington Deborah Brouwer, RN, CNN Director, Therapeutic & Clinical Programs Renal Solutions, Inc. Warrendale, Pennsylvania

2 Overview Cannulation of the Arteriovenous Fistula is designed to help you: Increase understanding of AV fistulas Increase knowledge of assessment, cannulation, and protection of new and mature fistulas Troubleshoot problems during cannulation and dialysis Communicate effectively with care team members Encourage 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 Cannulation Cannulation Site Selection and Preparation Cannulation Techniques Self-Cannulation Complications

4 Fact When 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 fistula Further hospitalization Creation of temporary access measures Inconvenience Disruption of regular treatment regimen Higher treatment costs

6 Mature Arteriovenous Fistula
- - Photo courtesy of J. Rowland

7 Arteriovenous Graft 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 complications Longevity Lowest costs Merrill D, et al. Dial Transplant. 2005;34:

10 Cannulating a Fistula The formal description of the process of inserting needles into a vascular access Graphic courtesy of Medisystems HemoDYNAMIC Devices™

11 Program Overview The new AV fistula: The mature AV fistula:
How to assess for: Maturity Complications Cannulation sites Correct way to cannulate it The mature AV fistula: How to assess How to select cannulation site How to prepare cannulation site How to cannulate site using site rotation and the buttonhole technique


13 Assessment of the New AVF for Maturity

14 Fistula Maturation Definition: 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 place Be less than 6 mm deep Have a blood flow greater than 600 mL/min Be evaluated for nonmaturation 4–6 weeks after surgical creation if it does not meet the above criteria National 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 treatment After the scar heals, begin assessing AVF using a “gentle” tourniquet placed high in the axilla area Instruct patient to start access exercises after healing (check with surgeon first) Document patient education as well as condition and maturation of the AVF

17 Fact Experienced 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 touch There should be no prominent collateral veins

19 Tourniquet Photo courtesy of J. Holland

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 bruit Document fistula maturation, patient education

22 During Physical Examination
Assess AVF for complications Thrombosis Stenosis Infection Steal syndrome Aneurysms Select 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 enough Vein feels prominent and straight Vein has a strong thrill and good bruit Physician order All of the above ANSWER: (All of the above)

25 Fistula Maturation What 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 study Physical exam by the: Nephrologist Nephrology nurse Surgeon Angiogram (fistulogram)

27 Best Tool/Technique? Physical Exam! Look, Listen, and Feel Use Your:
Eyes Ears Fingertips

28 Maturing Fistula Physical Exam
Firm, no longer mushy Vessel wall thickening Vessel diameter enlargement (to 4–6 mm) Absence of prominent collateral veins If in doubt, “Just Say No”

29 Inspection Look for: Changes compared to opposite extremity
Skin color/circulation Skin integrity Edema Drainage Vessel size/cannulation areas Aneurysm Hematoma Bruising

30 Look for Complications
Changes in Access Redness Drainage Infection Abscess Cannulation sites Aneurysms Extremity Skin color Edema Small blue or purple veins Hematoma Bruising Distal Areas of Access Extremity Hands/Feet: Cold Painful Steal Numb syndrome Fingers/Toes: Discolored Central 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 common Photo courtesy of L. Spergel, MD

33 Juxta-Anastomotic Stenoses
Most common AVF stenosis Vein segment immediately above the arterial anastomosis Stenosis also may be present in artery Caused by ? Trauma to segment of vein mobilized and manipulated by the surgeon in creating the AVF Beathard 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 inserted Make a fist with access arm dependent; observe vein filling Raise access arm; entire AVF should flatten/ collapse if no stenosis/obstruction If a segment of the AVF has not collapsed, stenosis is located at junction between collapsed and noncollapsed segment Instruct patient to perform this at home

35 Infection Lower rate with AVF compared with other access types1,2
Staphylococcus aureus the most common pathogen2 Patients and dialysis team personnel have high rates of Staphylococcus on skin3 Handwashing before, after, and between patients is critical4 1. 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

37 Aneurysm Localized ballooning

38 Signs and Symptoms of Complications
Differences in extremities Edema or changes in skin color = stenosis or infection Access Redness, drainage, abscess = infection Aneurysms Access extremities Small, blue/purple veins = stenosis Discolored fingers = steal syndrome

39 Signs and Symptoms of Complications (cont’d)
Temperature Changes Warmth of extremity = infection Coldness 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 section Adequate and consistent vein diameter

42 Palpation Temperature Change Thrill Warmth = possible infection
Cold = decreased blood supply Thrill Palpation can be started at the anastomosis Thrill diminishes evenly along access length Change can be felt at the site of a stenosis; becomes “pulse-like” at the site of a stenosis Stenosis may also be identified as a narrowed area

43 Palpation (cont’d) Feel for Size, Depth, Diameter, and
Straightness of AVF Feel the entire AVF from arterial anastomosis all the way up the vein Evaluate 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 Bruit Listen to entire access every treatment Note changes in sound characteristics (bruit): A well-functioning fistula should have a continuous, machinery-like bruit on auscultation An 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 order Experienced, qualified staff person Tourniquet

47 Post-Op Follow-up Communicate assessment findings with access team, including surgeon Check maturity progress every session Assure evaluation by surgeon 4 weeks post-op Intervene if there is no progress at 4 weeks or AVF is not mature and ready for cannulation at 6–8 weeks

48 Protocol for New AVF Cannulation

49 Protocol for New AVF Cannulation
Define successful cannulation Cannulation guidelines New AVF Mature AVF Unsuccessful cannulations Detailed 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/radiologist Protocol should provide: Clear instructions for the initial cannulation Subsequent cannulations Interventions for complications

51 Cannulation of New Fistula Policy & Procedure
See 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 cannulation Documentation guidelines for all cannulation procedures Unsuccessful cannulation Detail instructions to follow for any anticipated complications for both staff and patients Example: 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 cannulate Experienced, qualified staff person who is successful with new fistula cannulations Use 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 cannulation Words 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 modified Use 17-gauge needles initially Use saline-filled fistula needles with syringes attached (optional) Use a tourniquet

56 Needle Selection If patient has a catheter, use 1 lumen of the catheter and 1 needle in the fistula When 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 use Rationale: If an infiltration occurs, blood is not being forced back into the needle via the blood pump = smaller hematoma Also, permits pre–pump arterial pressure (AP) monitoring, which will help to determine if the fistula has a good access flow. 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 inflow Thus, lower risk of complications with arterial needle used as the first needle National 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 evaluation Enhance continuing education and training of dialysis staff Improve patient outcomes through 2 principal means: Reduced hospitalizations Fewer access complications

59 Cannulator Rating System
Level 1: New employee with no experience Level 2: New employee with experience Level 3: Current employee improving competency Level 4: Most experienced, competent cannulator

60 Preliminary Steps Reduce patient fears Educate patients
Choose your words carefully Adjust dialysis schedule Educate patients What they may feel during procedure Report symptoms of complications Consult nephrologist concerning heparin dose modification when initiating AVF use

61 Needle Selection Arterial needle for new AVF Rationale
Smaller hematoma if infiltration occurs Arterial needle permits pre-pump AP monitoring to evaluate blood flow Pre-pump AP ≤ –250 mm Hg at 200 mL/min (BFR) with a 17-gauge needle National 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 access should 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: Looking Inspect access for incisions/location of anastomosis Feeling Palpate access Gently compress access midpoint Arterial inflow will “pulse with flow” Venous outflow will have diminished or no pulse Listening Auscultate access Arterial inflow will have pulsatile sound Venous outflow will have minimal or no sound

64 Needle Gauge 17-gauge needle is strongly recommended for initial cannulation A fistula may appear and feel ready to cannulate, but the vessel wall may still be fragile and unable to tolerate the needle puncture The 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 hub Shallow new AVFs may benefit from shorter needles Shorter, 3/5″ AVF needles may advance fully into the shallow fistula

66 Adequacy of Needle Gauge
Compare needle with fistula Use 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 order General needle gauge guidelines and maximum BFR with the pre–pump AP ≤ –200 to –250 mm Hg 17-gauge needle = 200–250 BFR 16-gauge needle = 250–350 BFR 15-gauge needle = 350–450 BFR 14-gauge needle = > 450 BFR Must 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 for specific needle gauge and maximum BFR.

68 Non–back-eye needle—for venous use only
Use Back-Eye Needles Non–back-eye needle—for venous use only Back-eye opening allows blood intake from both sides of the needle; can be used as arterial or venous needle Arterial needle Venous needle

69 both the bevel and back-eye
Back-Eye Needle Flow Allows blood to enter or exit from both the bevel and back-eye

70 Determining Direction of Access Flow
Locate anastomosis Palpate Arterial inflow “pulses with flow” Venous outflow = diminished or no pulse Auscultate Arterial inflow = pulsatile sound Venous 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 size How does it compare to needle size? Compare size with and without tourniquet Determine 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 bleeding Consider the procedure for flushing and heparin locking the catheter lumens pre- and post-hemodialysis treatment to prevent excessive bleeding

73 Patient Education Inform patients of what they may feel during the initial cannulation procedure Ask 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 Direction Always cannulate the venous needle with the direction of the blood flow Always 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 heart Arterial needle directed toward the arterial anastomosis (retrograde) Photo courtesy of D. Brouwer

76 Needle Direction Photo courtesy of D. Brouwer
Venous needle directed back toward the heart Arterial needle also directed back 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 vessel Use of the tourniquet helps to engorge, visualize, palpate, and stabilize the AVF Use 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 needle Check/aspirate for blood return Then 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 occur National Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.

79 “Wet” Needle

80 When to Advance to 2 Needles
Only after the arterial needle functions without: Infiltration or hematoma Cannulation difficulties Access blood flow problems Excessively negative pre–pump arterial pressures Bleeding around the needle during dialysis Prolonged bleeding post-dialysis At 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 criteria Needle gauge in physician’s order Match 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 hematoma Cannulation difficulties Access blood flow problems Excessively negative pre–pump arterial pressures Excessive venous pressures Bleeding around the needle during dialysis Prolonged post-dialysis bleeding

84 Match Needle Gauge to Blood Flow Rate (BFR)
Maximum BFR 17-gauge < 300 mL/min 16-gauge mL/min 15-gauge 350–450 mL/min 14-gauge > 450 mL/min

85 Needle Gauge Smaller needle gauge requires lower BFRs
Needle gauge may be a specific physician order General needle gauge guidelines and maximum BFR with the pre–pump AP ≤ –200 to –250 mm Hg 17-gauge needle = 200–250 BFR 16-gauge needle = 250–350 BFR 15-gauge needle = 350–450 BFR 14-gauge needle = > 450 BFR Must 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 for specific needle gauge and maximum BFR.

86 Arterial and Venous Pressure Monitoring and Limits
A must, especially for a new fistula Pre–pump arterial pressure (AP) must be less negative than –250 mm Hg Venous pressure (VP) should not exceed the BFR with a 17-gauge needle Example: At BFR of 200 mL/min, VP should not exceed 200 mm Hg Follow unit-specific processes and procedures for needle gauge and maximum BFR National 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 pump AP exceeding –250 mm Hg – Significant drop in delivered blood flow – Hemolysis National 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 rate Stroke volume Actual delivered Qb URR / Kt/V outcomes _ + - 180mmHg Negative Pressure Created by pump stroke Affected by access Affected by needle gauge Affected by needle position Affected by tubing 450ml Actual 450ml *Shows the effect of a normal pre-pump arterial pressure on delivered flow

89 Pre-pump Arterial Monitoring
Excessively negative pre-pump arterial pressure* _ + - 280mmHg 450ml Actual 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 BFR Excessively negative pre–pump AP can be caused by anything that restricts arterial inflow to the blood pump: Inadequate blood flow from the access Needle gauge too small for prescribed BFR (ie, needle gauge “mismatch”) Obstructed needle Obstructed 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 BFR Varying pre–pump arterial pressures BFR pump setting Depner 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 demand Larger-gauge needles may be needed for higher BFR settings Check to make sure that needle is not obstructed or that blood line is not kinked Blood pump speed as prescribed may not be attainable and may need to be reduced if/until cause is identified and remedied Notify physician that access flow is not sufficient If 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 Removal Once the patient has had 6 successful treatments with the AVF, the registered nurse (RN) should obtain an order to have the catheter removed Successful = 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 compression Never use clamps Hold sites for 10 minutes—no peeking

99 Education for Patients
Check fistula daily for a thrill and bruit Check for signs and symptoms of infection or other complications Write instructions for infiltrations

100 Call the Nephrologist/Physician
Thrill is undetectable Patient becomes feverish, dehydrated, or experiences low blood pressure

101 Assessment of the Mature AVF

102 “Sleeves Up” Exam Assessment 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 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 AVF Photo courtesy of L. Spergel, MD

104 Cannulation Site Selection and Preparation

105 Physical Assessment Assess AVF before every cannulation
Compare arms for changes in skin color, circulation, integrity Inspect Access extremity for central or outflow vein stenosis Distal areas of extremity for steal syndrome Access for vessel size, cannulation areas, infection, aneurysms Palpate Temperature change may mean infection or stenosis Change in thrill may mean stenosis Auscultate Listen to entire access for changes in bruit that indicate stenosis

106 Identify Ideal Segment of AVF
Look and feel for a straight segment of AVF Segment must be as long as the needle length (ie, 1″ minimum) Stay at least 1.5″ from the AVF anastomosis The arterial and venous needles need to be 1″ to 1.5″ apart Avoid curves, flat spots, and aneurysms to prevent complications

107 Site Preparation Dialysis patients have more Staphylococcus spp (SA and MRSA) on their skin and in their nares (nose) than the general population Dialysis staff can also have a higher rate of staph carriage Common route of transmission of staph is from the nose to the skin to the vascular access = infection SA: Staphylococcus aureus MRSA: methicillin-resistant S aureus Kirmani 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 Preparation If possible, the patient should wash the access with antibacterial soap before coming to the chair Staph is the leading cause of infection in dialysis patients Photo courtesy of L. Ball Boyce 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 rates Once the skin site is properly cleansed, the skin should not be touched with bare hands or gloved hands If touched, re-prep the skin All site selection should be done prior to the final skin preparation

110 Applying Chlorhexidine Gluconate
Wet insertion site for 30 sec Allow to air-dry for ≈30 sec Do not blot or wipe

111 Applying Sodium Hypochlorite
Saturate sterile gauze pad Clean sites with circular motion Wait 2 minutes before proceeding

112 Proper Cleansing Technique
Proper needle-site preparation reduces infection rates Start where you are going to place the needle (the black dot) and cleanse in a circular, outward motion Do 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 patients Various 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 vessel Advantage: Numbs the area prior to the cannulation procedure Disadvantages: Can cause scarring, vasoconstriction, keloid formation, burning with injection, and poses a needle-stick risk

116 Topical Sprays Topical sprays (ethyl chloride) can be used to numb the skin sites Advantage: Noninvasive method of numbing the skin Disadvantages: Nonsterile, requires patient-specific bottle to prevent cross-contamination, may discolor or damage skin with long-term use, flammable contents in bottle Method: Spray arterial site, prep skin, then insert needle immediately; repeat for venous site

117 Topical Creams Topical creams contain lidocaine and may be applied by the patient at least 1 hour prior to treatment Advantage: Provides numbing to a larger cannulation area Disadvantages: 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 treatment Must 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 wrap Prior to cannulation, remove cream, wash/prep skin

119 Tourniquet Use Tourniquet required for all cannulations
Apply tightly enough to engorge vessel

120 Self-Cannulation

121 Why Offer Self-Cannulation?
Benefits for patients: Less painful Less likely to promote fear and anxiety Less stressful Greater feeling of control Inspires confidence Access may last longer Alternative 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: Accessed May 1, 2006.

123 What Are Professionals Saying?
Centers for Medicare & Medicaid (CMS) Fistula First Change Package #8: Cannulation Training for AVFs Facility offers option of self-cannulation to patients who are interested and able American Nephrology Nurses’ Association (ANNA) Position Statement: Vascular Access for Hemodialysis Education 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) Devices Training in self-cannulation should be considered in NHHD MEI Kidney School™ “Putting in your own needles is the best way to have your dialysis lifeline last as long as possible.” Vascular Access Society The buttonhole technique is recommended for self-cannulation

125 Plan Your Training Provide a quiet, calm environment
Allow the patient to ask questions Have the patient practice: Getting the “feel of the needles” with a practice arm Determining angle of insertion Assessing their access Putting on and taking off the tourniquet

126 Gather Supplies Gloves (2 pairs) Tape Antimicrobial prep Chux pad
Needles Tourniquet Scissor clamp Gauze Adhesive bandages Normal saline solution (NSS) Two 10-cc syringes Sharps container

127 Prepare the Needle Wash hands and access with soap and water; dry thoroughly Using 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 thrill Listen for a bruit Check for infection, bruising, hematoma, prior needle-insertion sites, curves, flat spots, stenosis, aneurysms, diameter, and depth Select sites for cannulation: Site rotation—stay 1.5″ away from anastomosis, keep 1–1.5″ between needle sites Buttonhole—locate prior scab sites

129 Clean the Site and Apply a Tourniquet
Cut all the tape you will need before cannulating Apply 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 tab When 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 skin Put 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-eye With your thumb and forefinger, grasp the needle wings together so the opening of the needle (bevel) is facing up Remove 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 smoothly Compress nerves, thus blocking your pain response for 20 seconds Based 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 skin Note: If the blood stops moving in the needle tubing or you feel resistance, STOP Once the needle is in the access, place a piece of 1″ paper tape over the wings This will keep needle from moving around in the access Open 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 line Apply 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 dialysis Pick up the venous needle and repeat the needle-insertion process Once 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 Pump Turn on the blood pump to 150–200 mL/min and allow blood to flow through the extracorporeal circuit until it reaches the venous drip chamber Turn the blood pump off and connect the venous blood tubing to the venous needle tubing Unclamp 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 access Open gauze package Carefully remove chevrons from both needles Carefully 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 pressure Have staff or helper remove the needle, then apply pressure to the needle site until bleeding stops Dispose of the needle in a sharps container Remove 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

139 Complications

140 Bleeding Bleeding during treatment (oozing around needle or infiltration) = fragile vessel wall or back wall penetration; don’t flip the needles Bleeding post–needle removal = fragile vessel wall or needle trauma or inadequate pressure at puncture sites Review needle-removal technique. Improper pressure with needle withdrawal = vessel damage A pattern of prolonged bleeding post–needle removal may indicate stenosis or clotting disorder. Evaluate bleeding after 20 minutes Educate 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 needle Don’t lift needle in vein Flush with NSS

143 Prevent Postdialysis Infiltrations
Apply gauze without pressure Remove needle at insertion angle Apply pressure with 2 fingers Hold pressure 10–12 minutes

144 Treating Infiltrations
Elevate arm above heart Ice 20 minutes on/20 minutes off for 24 hours Warm compresses after 24 hours Let fistula rest Second infiltration: Notify vascular access team Don’t use AVF until directed

145 Infiltrations in New AVF
Elevate arm above the level of heart While protecting the skin over access area with a clean cloth, gently apply: Ice 20 minutes on/20 minutes off for first 24 hours Warm 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 intervention Don’t use that AVF until further directed RN: registered nurse

147 How to Prevent Infiltrations
Check for flashback and aspirate Flush with NSS to ensure the needle flushes with ease and there are no signs or symptoms of infiltration Saline 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 not Use 2 fingers per site for hemostasis It is crucial to apply pressure to both the skin and access wall puncture sites Reprinted 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 site Tape to apply once the bleeding has stopped Information Card: Vascular access type/location Name 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 needle If poor flow persists after next session despite changing needle locations, refer to surgeon for evaluation and possible treatment options NOTE: Use tourniquet for cannulation only! Do not leave in place for entire treatment!!!

151 Aneurysm Caused by stenosis as vessel narrowing increases “back pressure,” causing vessel distension and weakening of vessel wall May also be caused or aggravated by frequent cannulations in the same area Photo courtesy of P. Cade

152 Stenosis Most common complication Causes: IV, CVC, PICC lines
Surgery to create AVF Aneurysms May be caused by the back pressure associated with stenosis Needle-stick injury

153 Types of Stenoses Juxta-anastomotic (most common stenosis in AVF)
Central-vein Juxta-anastomotic (most common stenosis in AVF) Mid-access Outflow Central vessel Outflow Mid-access Inflow Forearm AVF Graphic 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 Stenosis Clotting of the extracorporeal circuit 2 or more times/month Persistently swollen access extremity Changes in bruit or thrill (ie, becomes pulse-like) Difficult needle placement Blood squirts out during cannulation Elevated venous pressures

157 Clues to Stenosis (cont’d)
Excessively negative pre-pump AP Decreased blood pump speeds Inability to achieve BFR Changes in Kt/V and URR Recirculation Prolonged postdialysis bleeding Frequent episodes of access thrombosis Kt/V: kidney or dialyzer (treatment time) URR: urea reduction ratio Total volume of urea

158 Observe Access Extremity for Evidence of Stenosis
Perform a physical exam for AVF stenosis Perform before patient has needles inserted Have patient keep access arm dependent and make a fist—observe vein filling Have patient slowly raise the access arm—the entire AVF should collapse if no stenosis; if entire vein is not flat, indicative of stenosis If a segment of the AVF has not collapsed, stenosis is located at junction between collapsed and noncollapsed segment Patient can do this at home

159 Thrombosis Surgical/technical problems
Preexisting anatomic lesions (eg, old IV injury) Premature use Poor blood flow Hypotension Hypercoagulation Fistula compression

160 Infection AV 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 area Redness Increase in temperature Swelling, hardness Drainage from incision, needle sites Tenderness or pain Patient complaints without other indications of Malaise Fever

161 Prevention of Infection
General hygiene Pretreatment washing of access extremity Hand washing, before and after cannulation No scratching, irritation of skin of access extremity Precannulation Appropriate skin antisepsis Sufficient antiseptic-skin contact time Cannulate while antiseptic is wet or dry, as directed Cannulation Maintain needle sterility Do 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 extremity Steal 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 pulse Neurological and soft tissue damage to the hand can occur, resulting in mobility limitations (eg, grip strength, dexterity), loss of function, ulcerations, necrosis Steal 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 circulation Procedures, such as the DRIL (distal revascularization-interval ligation), can successfully treat steal and ischemia Individuals who are at high risk for developing acute steal are: Patients with diabetic neuropathy Patients with PVD Henriksson 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 quickly Necrotic tissue cannot be “fixed”—it must be removed Steal/ischemia places patients at risk for infection Infection increases their risk for hospitalization Hospitalization increases their risk for death!

167 Educational Goals Achieved
Understand the importance of AVF Upgrade your knowledge of cannulation techniques Troubleshoot problems Communicate 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:

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