1Vascular Access Evaluation and

Cannulation Training

Cheryl George RN, QI Nurse, ESRD Network 13 cgeorge@nw13.esrd.net 405.948.2249

Items to be completed for CEU credit BEFORE CLASS

Complete Pre-test

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~ ~ ~

AFTER CLASS

At end of class complete (hand in before you leave):

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EVALUATION

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2Disclaimer

This information was developed by ESRD Network 13 while under contract with the Centers for Medicare & Medicaid Services, Baltimore, Maryland, Contract #HHSM-500-2006-NW013C.

The contents presented do not necessarily reflect CMS policy.

Conflict of Interest Statement:

ESRD Network 13 does not endorse or recommend any product by representatives of any renal company. The information for this workshop is presented to assist in educating professionals in the area of ESRD.

Objectives Various HD Access Options

Assessment: Physical exam

Prep

Blood Flow Rate and Needle Gauge

Cannulation

Needle Removal and Hemostasis

Complications

Interactive: Cannulation Practice

Buttonhole technique

3AV FistulaWHY AVF IS BEST CHOICE

Native AV Fistula accesses have the best 4- to 5-year patency rates

Require fewer interventions compared to other access types

Have a lower incidence of infection than AVGs and Catheters

CMS goal: 66% Fistula

Utilization in ESRD Patients

KDOQI Guidelines recommends

only expert cannulators

cannulate new AVFs

AV Grafts

o Loop/straight grafts: 3-4 weeks healing time

o Always rotate cannulation sites to prevent pseudo-aneurysms

o Cannulate at 45 angle

o Confirm entry via blood flash-back

o Trend venous pressures for stenosis monitoring

o NewHeRO Vascular Access Device

4Fistula

Artery Vein

Graft

Artery Vein

Artery and vein

are

connected creating

an

opening between the two Artery and vein are connected

by a tube between the two vessels

o What is the HeRO device?

o The HeRO device is surgically implanted under the skin (subcutaneous) and allows repeated long-term access to a patients circulation for hemodialysis. The HeRO device consists of a conventional graft which shunts blood from the brachial artery into the central venous system (heart) via an outflow component. The HeRO device is intended for chronic hemodialysis patients who have exhausted peripheral access sites suitable for fistulas or grafts (i.e., access-challenged hemodialysis patients).

5SLEEVES UP!Evaluate Every AV Graft Patient for Possible Secondary AVF

Once a month, clinic rounds should include an examination of the AV graft extremity to the shoulder,by rolling sleeves up (or removing shirt if necessary).

After the upper arm is exposed to the shoulder, the hand or a tourniquet is used for light compression just below the shoulder to see if the outflow vein of the forearm graft appears suitable for immediate use as an AVF.

If this appears to be the case, (often this is the case if the cephalic vein is the outflow vein), the vein is evaluated by:

Refer patient for fistulogram (or Doppler study) to confirm that the outflow vein and draining system back to the heart is normal.

If fistulogram is normal, the vein is tested by cannulating the outflow vein, with the venous needle only for 2 consecutive dialysis sessions.

If both cannulation sessions are uneventful, the plan for surgical conversion of graft to upper arm fistula is discussed with patient, staff, nephrologists and surgeonand documented in chart.

If sleeves up evaluation does not identify a vein as being clearly suitable for conversion to an AVF.

Fistulogram or Doppler Ultrasound study should be ordered at the first signs of graft failure.

Catheters

< 10% of patients

Educate patients on catheter care

Use appropriate prep for caps and skin Skin prep solution may not be strong enough for capsFollow facility protocol!

Monitor closely Highest Risk of infectionS/S infection at exit site: Sepsis:Redness, Swelling, Drainage Undocumented hypotension

Fever

6Why is today important?

Improper cannulation

technique and skill level may

lead to:

premature access failure

patient fear or reluctance

Staff turnove

r

Assessment

Cannulation technique

Cannulation skill level

Infection

Fistula Development

Adequate Blood Flow

Needle Placement

A-V Direction

How can we prevent premature AVF access failure?o Good techniqueo Assessment of A-V Fistula

prior to cannulationo Skill level of cannulator

Definition: Process by which a fistula becomes

suitable for cannulation (ie, develops adequate

flow, wall thickness, and diameter)

Evaluate for non-maturation 46 weeks after

surgical creation if AVF does not meet the above criteria

Rule of 6s: In general, a mature fistula should:

Be a minimum of 6 mm (about inch)

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

Fistula Maturation

7NKF-K/DOQI Vascular Access Clinical Practice Guidelines - 2000

MONITORING (PHYSICAL) INDICATORS Inspection Palpation Auscultation Trending:

Bleeding/Swelling/Clotting/Cannulation

SURVEILLANCE (TEST) INDICATORS Intra-Access Blood Flow Static Venous Dialysis Pressure Dynamic Venous Dialysis Pressure Recirculation Arterial Dialysis Pressure (pre-pump) KT/V (URR) Doppler Ultrasound

K/DOQIPreferred

Assessment Best Tool/Technique?

Look Listen Feel

Do you perform a physical exam of your patients accessbefore each treatment?

8L K: Compare extremities

Color change

Anastomosis-signs of wound healing at the

surgical incision site of new maturing fistulas

Aneurysm

Signs of infection,

redness, drainage

or abscess formation

Listen:

To patient concerns

Pulse Soft, easily compressible is normal

Water hammer may indicate stenosis

Bruit Low pitch; Continuous; Diastolic and systolic is normal

High pitched ; Discontinuous; Systolic only may indicate stenosis

9Feel: for the thrill Compare extremities

Temperature Change

Diameter

growth should be apparent in new fistula 2 weeks after surgery

note any flat spots

firmness indicates thickening (development) of vessel wall

Thrill

Palpate from anastomosis along fistula

Continuous purring or vibration, not a strong pulsation

Diminish evenly along access length?

Changes may be felt at the stenosis site if present

Pulse-like at site of stenosis

Stenosis may be identified as a narrowed area

Normal Findings include:purring or vibrating (thrill) diminishing evenly along the length of the access

StenosisA narrowing of the vessel

Normal Narrowing Clotted

Thrill/Bruit Pulsatile

Collapsed - With Elevation Dilated

Pressure

Strong pulsation felt during palpation of the fistula during the assessment indicates stenosis

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Clinical Indicators of Stenosis Persistently swollen access

extremity

Changes in bruit or thrill

Difficult needle placement

Clotting the system 2 or more times/month

Prolonged bleeding post-dialysis

Elevated venous pressure

(frequent alarms)

Excessive negative prepump arterial pressure (frequent alarms)

Recirculation

Frequent episodes of access thrombosis

Decreased blood pump speeds, changes in Kt/v and URR

Monitor for Stenosis Perform a physical exam for AVF

stenosis before patient has needles

inserted

Have patient keep access arm

dependent and make a fist

observe vein filling

Have patient slowly raise the

access armthe 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 non-collapsed segment

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Listen:

Pulse Soft, easily compressible is normal

Listen:

High pitched ; Discontinuous; Systolic only may indicate stenosis

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Access Evaluation for Ischemia (CPG 5.6.1)KDOQI Guidelines 2006

Elderly and hypertensive patients with a history of peripheral arterial occlusive disease and/or vascular surgery, as well as patients with diabetes, are prone to develop access-induced steal phenomenon and steal syndrome

Staging according to lower-limb ischemia:

Stage I, pale/blue and/or cold hand without pain;

Stage II, pain during exercise and/or HD;

Stage III, pain at rest;

Stage IV, ulcers/necrosis/gangrene

Therapeutic options

Dilation

Banding

Distal revascularization

If ischemic manifestations threaten the viability of the limb, the outflow of the fistula should be ligated.

Infection Prevention and Site Preparation

Dialysis patients have more Staph 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

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K/DOQI: Infection (CPG 5.7)Infections of fistulae are rarepotentially lethal impaired

immunologic status of ESRD patients.

Very rare access infections at the AV anastomosis

require immediate surgery

Majority of infections in AVFs occur at cannulation sites

Stop cannulation at that site/arm should be rested.

In all cases of AVF infection, antibiotic therapy is a must.

1-Broad spectrum vancomycin plus an aminoglycoside.

2-Conversion to the appropriate antibiotic is indicated based of

culture and sensitivities. *Treated for a total of 6 weeks.

A serious complication of any

access-related

infection may result in

sub-acute bacterial endocarditis

If possible, the patient should wash the access with antibacterial soap before coming to the chair

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KDOQI Guidelines1. Locate and palpate the needle cannulation

sites prior to skin preparation.2. Wash access site using an antibacterial soap

or scrub (eg, 2% chlorhexidine) and water.3. Cleanse the skin by applying 70% alcohol

and/or 10% povidone iodine using a circular rubbing motion.

Notes:Alcohol has a short bacteriostatic action time

and should be applied in a rubbing motion for 1 minute immediately prior to needle cannulation.

Povidone iodine needs to be applied for 23 minutes for its full bacteriostatic action to take effect and must be allowed to dry prior to needle cannulation. Clean gloves should be worn by the dialysis staff for cannulation. Gloves should be changed if contaminated at any time during the cannulation procedure. New, clean gloves should be worn by the dialysis staff for each patient.

Skin-PreparationTechnique for

PermanentAV Accesses

A clean technique for

needle cannulation

should be used for all

cannulation procedures(evidence)

Proper needle-site preparation reduces infection rates

If touched, re-prep the skin

Start where you are going to place the needle (the black dot) and cleanse in a circular,outward motion following your facilitys policy and procedure

Once the skin site is properly cleansed, the skin should not be touched with bare hands or gloved hands

Needle site

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Locating the Cannulation Site

Look for straight areas of at least 1

for each cannulation site

If you try to straighten out by pulling on the vessel to cannulate, the vessel will retract into its original position when released and lead to an infiltration

Avoid aneurysms and flat or thinned-out areas

Stay 1.5 to 2 away from the anastomosis

Keep the needles at least 1.5 apart

Each treatment requires 2 new sites (rotate each tx)

Check Direction of Flow by:

Looking Inspect access for incisions/location of anastomosis

FeelingPalpate accessGently compress access midpointArterial inflow will pulse with flowVenous outflow will have diminished or no pulse

ListeningAuscultate accessGently compress access midpointArterial inflow will have pulsatile soundVenous outflow will have minimal or no sound

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Needle Direction

Venous needle must always be placed in the same direction as the blood return back to the heart

Arterial needle can be placed against the inflow or back toward the heart (opinion)

Changing the Needle Site:Why Is Changing Needle Site Insertion Important?

One-siteitis: Causes aneurysm and stenosis formation

(Exception: Buttonhole)

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AV GRAFT Sites were Not Rotated.

AV FISTULA Aneurysm

Caused by sticking needles in the same general area

Aneurysm can also result from stenosis beyond theaneurysm, causing elevated back pressure

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Risk of Rupture

Aneurysm showing skin breakdown, color changes, large wound.

Photo courtesy of Rick Luscombe

Risk of RuptureA hemorrhagic blister like lesion (very thin wall) on an AVF with or without aneurysm.Have patient go immediately to the ER for immediate surgery or they will die. It's a rare occurrence, but if not recognized then usually fatal.

blister

Photo courtesy of Vo Nguyen, MD. In this case, the blister was associated with MRSA sepsis and was not even associated with a cannulation site. Protocol at this unit was activated in which an upper arm BP cuff was placed (not inflated), but available to totally occlude the arm artery system, should the blister rupture before local emergency folks can transport to the ER, where surgeon should be waiting. This blister did rupture while the patient was in ICU waiting for surgery. Fortunately, this patient survived.

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Rupture

Does Your Facility Have a PLAN?

Choosing the Needle Gauge

Initial Cannulation of a New Fistula

ie. start with one needle / 17ga / arterial line

* about 3 txs / no infiltrations or bleeding around sites

Smaller needle gauge requires lower blood flow rates (BFRs)

Needle gauge may be a specific physician order or facility protocol

Must monitor prepump AP to prevent excessive negative

pressure from the blood pump drawing on the vascular access.

Prepump AP should be in a range of 200 to 250 mm Hg

for all needle gauges and BFRs

*Follow your unit-specific nursing policy and procedure for

specific needle gauge and maximum BFR.

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Needle Gauge Guidelines

General needle gauge guidelines and maximum BFR with the prepump AP 200 to 250 mm Hg

17-gauge needle = 200250 BFR

16-gauge needle = 250350 BFR

15-gauge needle = 350450 BFR

14-gauge needle = > 450 BFR

Negative Pressures

APs exceeding < -250 may damage the vessel and destroy blood cells

AP should not exceed a 50% of the blood pump speed based on using a 15-gauge needle (BFR 400=AP-200)

Excessively negative 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 (Qb)

(ie, needle gauge mismatch, like drinking cola from a coffee stirrer/straw)

Obstructed needle (blood clot, cholesterol)

Obstructed or kinked line (a kinked arterial blood line

can cause life-threatening hemolysis)

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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 acceptthe prescribed needle gauge

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

Lidocaine Topical sprays (ethyl chloride) Topical creams Cannulation Technique

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Patient AnxietyCannulation can:

Provoke anxiety for the patients.Cause physical and/or psychological Pain

Good technique can provide accuracy and less pain

Only experienced cannulators should stick a NEW Fistula

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)

Tourniquet Use Required for all AVF cannulation procedures

Includes large AV fistulae that appear dilated without a tourniquet.

Ensures uniform dilatation of the vessel prior to needle insertion

Apply tight enough to enlarge or

engorge the vessel, but not tight

enough to cause pain or loss of blood flow to the limb

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Needle Insertion

Grasp the needle wings together so the needle has the opening (bevel) facing upward. Watch the orientation of the needle bevel, and avoid turning your wrist

If the bevel enters sideways, this can cause cutting of the vessel and/or a sidewall infiltration

Use only a back-eye needle for the arterial needle

The venous needle can be back-eye or nonback-eye

Angles of Entry Rule of Thumb:

2035 angles for fistulae

45 for grafts

Reality:

Not every access fits the rule of thumb;

Some AV fistulae are very shallow and a lesser angle can be used

You will need to carefully assess the depth of the access and adjust the angle of cannulation accordingly

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Cannulating the Fistula2035 angle of insertion depending on the depth of the access

Fistula needle/wings are the extension of your hands and fingersCareful not to touch needle withgloves/fingertips

Light pressure Once the AVF vessel is entered, the blood

flashback is visible in the needle tubing

Level out and slowly advance the needle with very minimal pressure

No need to flip needle Careful use of the tourniquet Careful application of tape

The angle is from the skin to the needle hub

L Technique

Hold thumb and index finger as an L

Thumb holds skin taut over fistula

Index finger stabilizes and engorges fistula

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Three-Point

Technique

Stabilize vessel

Pull skin taut toward

the cannulator to allow

easier needle insertion

* (compresses nerve endings, blocking pain sensation to the

brain for about 20 seconds)

Placement Is Crucial Do not flip or rotate the bevel of the needle 180

Flipping can cause stretching of the needle-insertion site and lead to bleeding during treatment (oozing around needle)

Flipping may also result in coring or tearing of the vessel wall leading to infiltration and damage to the access which may require surgical intervention

Use of back-eye needles eliminates the

need to flip, or rotate, the needle bevel 180

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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

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

Stents

Puncture through stent monolayer areas and rotate sites.

Avoid stent overlap zones

Do not rotate (flip) needles once the stent is punctured

Utilize strict aseptic technique during trans-stent needle access to minimize chances of infection

Infection can result in the need to remove stent

Whats your relationship with your patients Interventionalist and Surgeon?

Any time your patient goes in for anyIntervention

Contact Interventionalist /Surgeon for special instructions!

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Securing the needles

Secure wings

Sterile gauze or adhesive bandage over insertion site

Chevron to prevent dislodging

Additional tape as needed

Post-Treatment Hemostasis

Pull needle completely from the vein before pushing down on the needle site

Hold direct pressure for 10 minutes without peekingno exceptions

Do not use clamps unless absolutely necessary!

Clamps should never be used with a New Fistula

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Clamps vs. Holding Sites Patients and/or family should be taught to hold sites properly; otherwise, staff should hold sites

Compression of the sites in the presence of hypotension can cause the access to clot

Clamps should not be used routinely; however, if clamps must be used:

Use only 1 at a time

Be sure they are adjustable

Check for thrill above the clamp to ensure vessel is not occluded

Clamps should never be left on longer than 20 minutes

(bleeding longer than 20 min needs to be investigated)

Infiltrations in New Fistula

Elevate arm above the level of heart

Protect 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

Let it rest until the swelling is resolved

If the fistula infiltrates a second time, the RN should notify the vascular access team, including the surgeon, as soon as possible for intervention

Dont use the AVF until further directed

Patient instructions must be clear with a take home instruction sheet

DOCUMENT THE EVENT!

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Preventing Infiltrations

Check for flashback and aspirate

Consider use of wet stick

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

Avoid flipping needles

Hematoma If bruising or hematoma occurs after dialysis,

surface skin site has sealed

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

Use 2 fingers per site for hemostasis

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Tracking TrendingAdverse Occurrences Infection Infiltrations Clotted Access Pressure Monitoring

How do you track this information?

Do you consistently document these events?

Who trends, and what do you do with the info? Problem with a particular staff member? More education needed?

Particular patient? Intervention needed?

Particular set of patients? Same Surgeon? Same Interventionalist? More education needed?

Does your facility have triggers to know when to investigate and

make an ACTION PLAN?

Be Proactive!

If your patients AVF is not maturing or you suspect a problem.

Ask the Nephrologist if you can schedule them to see their Surgeon or an Interventionalist

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Practice Time

Questions?

Split up into two groups and practice the cannulation techniques you have learned.

Where to Get More Information

For further information on cannulation and

other AVF issues, please visit the official

Fistula First Web site at: www.FistulaFirst.org

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References

KDOQI Guidelines for Vascular AccessNational Kidney Foundation. Am J Kidney Dis. 2001;37(suppl 1):S137S181.Cannulation of the Arteriovenous Fistula (AVF) Authors: Lynda K. Ball, RN, BSN, CNN Deborah Brouwer, RN

Physical Examination of Dialysis Vascular Access by Gerald Beathard, MD

06-ProximalRadialArteryAVFFlowDiagram_Jennings.ppt

Use of Stent Grafts in Hemodialysis Vascular Access John M. Duch, MD, Lincoln Nephrology and Hypertension

I:\QI\QI Work Plan\2008\OVERALL 2008 QIWP\VA workshop training activity 2008-2009\ Fistula Cannulation Training