Transcript Slide 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
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”
2
Overview
•
•
•
•
•
•
3
(cont’d)
Assessment of the New AVF for Maturity
Protocol for New AVF Cannulation
Cannulation Site Selection and Preparation
Cannulation Techniques
Self-Cannulation
Complications
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.
4
Fistula First, National Vascular Access Improvement Initiative. Available at:
www.fistulafirst.org/professionals/tools.php. Accessed January 11, 2007.
Risks Associated with Poor
Cannulation & Improper Care of Fistula
•
•
•
•
•
•
5
Loss of the fistula
Further hospitalization
Creation of temporary access measures
Inconvenience
Disruption of regular treatment regimen
Higher treatment costs
Mature Arteriovenous Fistula
-
6
Photo courtesy of J. Rowland
Arteriovenous Graft
7
Photo courtesy of J. Rowland
Catheter Used for Dialysis
8
Photo courtesy of J. Rowland
Benefits of Arteriovenous
Fistula (AVF)
• Benefits of Arteriovenous Fistula (AVF)
– Lowest rate of failures and complications
– Longevity
– Lowest costs
9
Merrill D, et al. Dial Transplant. 2005;34:200-208.
Cannulating a Fistula
• The formal
description of the
process of
inserting needles
into a vascular
access
10
Graphic courtesy of Medisystems HemoDYNAMIC Devices™
Program Overview
• The new AV fistula:
– How to assess for:
 Maturity
 Complications
 Cannulation sites
– Correct way to cannulate it
• The mature AV fistula:
–
–
–
–
11
How to assess
How to select cannulation site
How to prepare cannulation site
How to cannulate site using site rotation and the
buttonhole technique
12
Assessment of the
New AVF for
Maturity
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
14
National Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.
Clinical Clarification
• The fistula should be examined regularly
following surgery. At 4 weeks post
surgery, the fistula should be evaluated
specifically for nonmaturation.
15
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
16
Fact
• Experienced dialysis nurses have an 80%
success rate for identifying fistula maturity.
17
Robbin ML, et al. Radiology. 2002;225:59-64.
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
18
Tourniquet
19
Photo courtesy of J. Holland
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.
20
1. Rus RR, et al. Hemodialysis Int. 2005;9:275-280.
2. Leaf DA, et al. Am J Med Sci. 2003;325:115-119.
3. Oder TF, et al. ASAIO J. 2003;48:554-555.
During Maturation
• Feel for strong thrill at arterial anastomosis
• Listen for continuous low-pitched bruit
• Document fistula maturation, patient
education
21
During Physical Examination
• Assess AVF for complications
– Thrombosis
– Stenosis
– Infection
– Steal syndrome
– Aneurysms
• Select cannulation sites
22
Is This New AVF Mature
and Ready for Cannulation?
AVF
23
Photo courtesy of D. Brouwer
Is This AVF Mature and Ready
for the Initial Cannulation?
a)
b)
c)
d)
e)
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)
24
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?
25
Diagnostic Tools/Techniques to
Determine If an AVF Is Ready
• Duplex Doppler study
• Physical exam by the:
– Nephrologist
– Nephrology nurse
– Surgeon
• Angiogram (fistulogram)
26
Best Tool/Technique?
Physical Exam!
Look, Listen, and Feel
Use Your:
Eyes
Ears
Fingertips
27
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”
28
Inspection
Look for:
 Changes compared to opposite extremity
 Skin color/circulation
 Skin integrity
 Edema
 Drainage
 Vessel size/cannulation areas
 Aneurysm
 Hematoma
 Bruising
29
Look for Complications
Changes in Access
•
Redness
•
•
•
•
Drainage
Abscess
Cannulation sites
Aneurysms
Changes in Access
Extremity
•
Skin color
•
Edema
•
Small blue
or purple
veins
•
Hematoma
•
Bruising
30
Infection
Central
or
outflow
vein
stenosis
• Distal Areas of Access
Extremity
• Hands/Feet:
Cold
Painful
Steal
Numb
syndrome
• Fingers/Toes:
Discolored
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.
31
Stenosis
• Frequent cause of
early fistula failure
• Juxta-anastomotic
stenosis most
common
32
Stenosis
Photo courtesy of L. Spergel, MD
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
33
Beathard GA. A Multidisciplinary Approach for Hemodialysis Access. New York, NY; 2002:111–118.
Beathard GA. Semin Dial. 1998;11:231–236.
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
34
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
35
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: www.dopps.org.
3. Kirmani N, et al. Arch Intern Med. 1978;138:1657-1659.
4. Boyce JM, Pittet D. MMWR 2002;51(RR16):1-44.
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
36
Aneurysm
• Localized ballooning
37
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
38
Signs and Symptoms of
Complications (cont’d)
• Temperature Changes
– Warmth of extremity = infection
– Coldness of extremity may = steal syndrome
39
Thrill for Stenosis
• Abrupt change or loss
• Pulse-like
Narrowing of vein = stenosis
40
Feel for Cannulation Sites
• Superficial, straight vein section
• Adequate and consistent vein diameter
41
Palpation
Temperature Change
 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
42
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
43
Auscultation
Listen for the Nature of the Bruit
44
Photo courtesy of J. Holland
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
45
Requirements for Cannulation
• Physician order
• Experienced, qualified staff person
• Tourniquet
46
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
47
Protocol for New
AVF Cannulation
Protocol for New AVF
Cannulation
Define successful cannulation
• Cannulation guidelines
– New AVF
– Mature AVF
– Unsuccessful cannulations
• Detailed instructions for complications
49
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
50
Cannulation of New Fistula
Policy & Procedure
See FistulaFirst.org for entire Policy & Procedure.
51
National Vascular Access Improvement Initiative Web site.
Available at: www.fistulafirst.org. Accessed April 21, 2006.
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?
52
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)
53
National Vascular Access Improvement Initiative Web site.
Available at: www.fistulafirst.org. Accessed April 21, 2006.
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)
54
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
55
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)
56
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 200
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
57
National Vascular Access Improvement Initiative Web site.
Available at: www.fistulafirst.org. Accessed April 21, 2006.
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
58
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
59
Preliminary Steps
• Reduce patient fears
– 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
60
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
61
National Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.
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
62
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
63
 Gently compress access midpoint
 Arterial inflow will have pulsatile sound
 Venous outflow will have minimal or no sound
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)
64
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
65
Adequacy of Needle Gauge
• Compare needle with fistula
• Use 3/5″ needle for shallow AVF
66
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.
67
Use Back-Eye Needles
Back-eye opening allows
blood intake from both
sides of the needle; can
be used as arterial or
venous needle
Arterial needle
68
Non–back-eye
needle—for
venous use only
Venous needle
Back-Eye Needle Flow
Allows blood to
enter or exit from
both the bevel and back-eye
69
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
70
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
71
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
72
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)
73
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
74
Needle Direction
Venous
needle
directed
back
toward the
heart
Arterial
needle
directed
toward the
arterial
anastomosis
(retrograde)
75
Photo courtesy of
D. Brouwer
Needle Direction
Venous
needle
directed
back
toward the
heart
Arterial
needle also
directed
back toward
the heart
(antegrade)
76
Photo courtesy of
D. Brouwer
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
77
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
78
National Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.
“Wet” Needle
79
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
80
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.
81
Advancing Needle Gauge
• Use same criteria
• Needle gauge in physician’s order
• Match the needle gauge to hemodialysis
blood flow rate
82
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:
–
–
–
–
–
–
–
83
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
Match Needle Gauge to Blood
Flow Rate (BFR)
84
Needle Gauge
Maximum BFR
17-gauge
< 300 mL/min
16-gauge
300-350 mL/min
15-gauge
350–450 mL/min
14-gauge
> 450 mL/min
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.
85
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
86
National Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.
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
87
National Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.
Pre-pump Arterial Monitoring
Normal Range*
_
+
Effect on Delivered Blood Flow
• Refill rate
• Stroke volume
- 180mmHg
• Actual delivered Qb
• URR / Kt/V outcomes
Negative Pressure
• Created by pump stroke
• Affected by access
• Affected by needle gauge
• Affected by needle position
450ml
• Affected by tubing
Actual 450ml
*Shows the effect of a normal pre-pump arterial pressure on delivered flow
88
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)
89
WARNING!
• Do not disarm the AP monitor, and always
check to be sure that the pressure
transducer is not wet and is functioning.
90
Fistula First, National Vascular Access Improvement Initiative. Available at:
www.fistulafirst.org/tools.htm. Accessed January 11, 2007.
Clinical Clarification
• Anything that makes it difficult for the
pump to “pull” blood from the access will
make the pre-pump AP excessively
negative.
91
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)
92
Actual BFR
Actual Blood Flow Rate Decreases
as Pre–Pump AP Becomes More Negative
Varying
pre–pump
arterial
pressures
BFR pump setting
93
Depner TA, et al. ASAIO Trans. 1990;36:M456–M459.
Clinical Clarification
• The danger of excessively negative prepump AP is that it causes a reduction in
actual delivered blood flow, and also can
cause hemolysis (destruction of red blood
cells).
94
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
95
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
96
Clinical Clarification
• It is important to actively engage your
critical thinking skills when deciding on the
appropriate timing of catheter removal.
97
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
98
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
99
Call the
Nephrologist/Physician
• Thrill is undetectable
• Patient becomes feverish, dehydrated, or
experiences low blood pressure
100
Assessment of the
Mature AVF
“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 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.
102
Spergel LS. Protocol. National Vascular Access Improvement Initiative Web site.
Available at: www.fistulafirst.org. Accessed June 26, 2006.
“Sleeves Up” Exam…
Outflow vein
(cephalic v.)
of failing
forearm AV
graft is
suitable for
conversion
to AVF
103
Photo courtesy of L.
Spergel, MD
Cannulation Site
Selection and
Preparation
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
105
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
106
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
107
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.
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
108
Boyce JM, Pittet D. Guidelines for hand hygiene in health-care settings.
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm. Accessed April 28, 2006.
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
109
Applying Chlorhexidine
Gluconate
• Wet insertion site for 30 sec
• Allow to air-dry for ≈30 sec
• Do not blot or wipe
110
Applying Sodium Hypochlorite
• Saturate sterile gauze pad
• Clean sites with circular motion
• Wait 2 minutes before proceeding
111
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
112
Says Who?
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.
113
1. 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.
2. Wash access site using an
antibacterial soap or scrub and water.
3. 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.
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
114
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
115
Topical Sprays
• Topical sprays (ethyl chloride) can be used to
numb the skin sites
• Advantage: Noninvasive method of numbing
the skin
• Disadvantages: Nonsterile, requires patientspecific 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
116
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
117
Using Topical Creams
•
•
•
•
118
Wash skin first
Apply 1 hour before dialysis
Cover with plastic wrap
Prior to cannulation, remove cream,
wash/prep skin
Tourniquet Use
• Tourniquet required for all cannulations
• Apply tightly enough to engorge vessel
119
Self-Cannulation
Why Offer Self-Cannulation?
• Benefits for patients:
–
–
–
–
–
–
–
121
Less painful
Less likely to promote fear and anxiety
Less stressful
Greater feeling of control
Inspires confidence
Access may last longer
Alternative hemodialysis options
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.”
122
Quotes from the Kidney School™. Available at: www.kidney school.org. Accessed May 1, 2006.
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
123
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
124
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
125
Gather Supplies
•
•
•
•
•
•
126
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
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
127
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
128
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)
129
– All AVFs must have a tourniquet
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
130
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
131
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)
132
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
133
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 needleinsertion 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
134
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
135
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
136
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
137
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
138
Complications
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
140
Infiltration = Hematoma
141
Photo courtesy of D. Brouwer
Prevent Cannulation
Infiltrations
• Don’t flip needle
• Don’t lift needle in vein
• Flush with NSS
142
Prevent Postdialysis
Infiltrations
•
•
•
•
143
Apply gauze without pressure
Remove needle at insertion angle
Apply pressure with 2 fingers
Hold pressure 10–12 minutes
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
144
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
145
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
146
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
147
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
148
Reprinted with permission of L. Ball and the American Nephrology Nurses' Association
publisher, Nephrol Nurs J. 2006;33:302.
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:
1. Vascular access type/location
2. 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
149
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!!!
150
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
151
Photo courtesy of P. Cade
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
152
Types of Stenoses
• Juxta-anastomotic
(most common
stenosis in AVF)
Central-vein
Outflow
• Mid-access
Mid-access
• Outflow
• Central vessel
Inflow
Forearm
AVF
153
Graphic courtesy of L. Ball
Central-vein Stenosis
154
Images courtesy of Microvena Corp
Distended, Obstructed Left Shoulder
Veins Indicative of Central-vein Stenosis
155
Photo courtesy of J. Holland
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
156
Clues to Stenosis (cont’d)
•
•
•
•
•
•
•
157
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)
Total volume of urea
URR: urea reduction ratio
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
158
Thrombosis
• Surgical/technical problems
• Preexisting anatomic lesions (eg, old IV
injury)
• Premature use
• Poor blood flow
• Hypotension
• Hypercoagulation
• Fistula compression
159
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
160
Prevention of Infection
• Prevention
– 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
161
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)
162
Clinical Clarification
• Steal syndrome is estimated to occur in
approximately 5% of vascular access
patients, mostly those with diabetes and
peripheral vascular disease.
163
Henriksson AE, Bergqvist D. J Vasc Access. 2004;5:62–68.
“Claw Hand” Contracture
From Steal Syndrome
164
Photo courtesy of J. Holland
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
165
Henriksson AE, Bergqvist. J Vasc Access. 2004;5:62–68.
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!
166
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
167
For further information
on cannulation and
other AVF issues,
please visit the official
Fistula First Web site at:
www.FistulaFirst.org