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November-December 2005 
Vol. 32, No. 6 
 Improving Arteriovenous Fistula Cannulation Skills 
 Lynda K. Ball, BS, BSN, RN, CNN 
, is the Quality Improvement Coordinator, Northwest Renal Network, Seattle, WA, and instructor, Clover Park Technical College Hemodialysis Technician Program, Tacoma, WA. She is the ANNA Western Region Vice President, and a member of the Greater Puget Sound Chapter.
The analyses upon which this publica- tion is based were performed under Contract Number 500-03-NW16 entitled End Stage Renal Disease Networks Organization for the States of  Alaska, Idaho, Montana, Oregon and Washington,sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products,or organizations imply endorsement by the U.S.Government. The author assumes full responsibility  for the accuracy and completeness of the ideas pre- sented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare & Medicaid Services, which has encouraged identification of quality improve- ment projects derived from analysis of patterns of  care, and therefore required no special funding on the part of this contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.
he National Vascular AccessImprovement Initiative, Fistula First, sponsored by the Centersfor Medicare & Medicaid Ser-vices (CMS), has contributed to anincreased number of arteriovenousfistulae (AVF) in the prevalent hemo-dialysis population throughout thecountry from 32% in December 2002to 37.4% in December 2004. The indi-vidual ESRD Network increases canbe seen in Figure 1.As different as individuals are onthe outside, it should not be a surprisethat individuals are also different onthe inside. If we could see within thebody, we would see blood vessels of varying sizes – some straight asarrows, some tortuous, and still othersundulating up and down. Because of this variation, cannulation of AVFs istechnically more challenging thancannulation of AV grafts (Allon &Robbin, 2002). We also have to takeinto consideration the co-morbiditiesof each individual patient, such as car-diac disease, diabetes, and peripheralvascular disease, because these canaffect blood flow through the access,fistula development, and the qualityof vessels available for access cre-ation. More challenging accessesrequire an increased level of expertiseof patient care staff for successful can-nulation. Some dialysis facilities areexperiencing a high turnover of trained individuals which may nega-tively impact the level of cannulationskills available (Hemphill & Allon,2003). The assessment process, can-nulation problems, and different can-nulation techniques will be discussedin an effort to assist patient care staff,old and new, to identify areas of improvement in their cannulationpractices.
Nurses can think of themselves asdetectives, looking for clues of prob-lems that could negatively impact thepatients’ vascular accesses. Different problems have different sets of clues.Recognizing these clues helps pro-vide successful dialysis treatments.Assessment of vascular accessinvolves inspection, palpation, andauscultation. It is necessary that vas-cular accesses be evaluated prior toevery cannulation using these threeaspects of nursing care.
Initially, a cursory inspectionshould include comparing one arm tothe other looking for ecchymosis, dis-coloration, breaks in the skin, anderythema. Closely inspect the armcontaining the access, looking for
Cannulation of arteriovenous fistulae is technically more challenging than cannulation of arteriovenous grafts. With the advent of the National Vascular Improvement Initiative, Fistula First, the United States has seen an increase in the number of arteriovenous fistulae.The problem we now face is how to refocus and reeducate nurses to the intricacies of arteri- ovenous fistula cannulation. Through evidenced-based practice and current best-demonstrat- ed practices, this article will provide the tools needed to improve arteriovenous fistulae can- nulation skills.
Cite evidence-based, best demonstrated practices to utilize in improving individ-ual cannulation technique.
1. Describe the assessment process of auscultation, palpations, and inspectionfor an AV fistula.2. List five clinical indicators that would indicate a stenosis.3. Explain the differences between the rope ladder and buttonhole techniques.
 Lynda K. Ball 
This offering for 1.5 contact hours is being provided by the American Nephrology Nurses’Association (ANNA). ANNA is accredited as a provider of continuing nursing education by the AmericanNurses Credentialing Center’s Commission on Accreditation. ANNA is a Provider approved by theCalifornia Board of Registered Nursing, provider number CEP 00910.The Nephrology Nursing Certification Commission (NNCC) requires 60 contact hours for eachrecertification period for all nephrology nurses. Forty-five of these 60 hours must be specific to nephrologynursing practice. This CE article may be applied to the 45 required contact hours in nephrology nursing.
November-December 2005 
Vol. 32, No. 6 
aneurysm or hematoma formations,curves, flat spots, prior cannulationsites, hand or arm swelling, discol-oration of nail beds, and the presenceof accessory veins (AmericanNephrology Nurses’ Association,2005).
Palpation is the next assessment process. Palpation enables one todetermine the patency of the fistula by assessing the thrill. A thrill is thesensation that is felt over the anasto-mosis –where the vein and arteryhave been surgically joined together.The vibration or purring that is felt isturbulence of the blood flow that iscreated by the high pressure arterialsystem merging with the low pressurevenous system. According to Dr.Gerald Beathard (2000), an interven-tional nephrologist who writes exten-sively on vascular access assessment,the thrill is usually only felt at theanastomosis and, if it is felt in anyother area of the access, it could be anindication of a venous stenosis. Someindividuals with very strong bloodflow will have a thrill the entire lengthof their accesses, so it will be impor-tant to make sure the thrill is continu-ous, indicating that no interruption of flow is occurring. If there is no thrillpresent, no needles should be placeduntil further evaluation with a stetho-scope is completed and the physicianis notified.Another reason to palpate theaccess is for evaluation of needleplacement. Tourniquets should alwaysbe used on fistulae, both oldand new,to help visualize potential cannula-tion sites, to get a better feel of theaccess in order to determine thedepth and proper angle of insertion,and to stabilize the vein to keep it from rolling during cannulation.Palpate the entire length of theaccess, checking for constant veindiameter, flat spots, and aneurysms.Palpation should also be used tocheck skin temperature. Warm skincan be indicative of infection, whichis usually accompanied by increasedtemperature, redness, and drainageor site tenderness. Cold skin couldindicate a decreased blood supply tothe extremity, and, if present, theradial pulse should be checked fordecreased circulation and the nailbeds examined for discoloration andcapillary refill of greater than 3 sec-onds. Always compare the accessarm temperature to the temperatureof the contralateral extremity.
Auscultation is the third evaluationprocess that should be used for a vas-cular access assessment prior to everytreatment. There must always be base-line information before beginning anyprocedure. Listening for the sound andcharacter of blood flow through a fis-tula is vital – remembering that theaccess is the patient’s lifeline and it must remain patent. Listen for thebruit – the whooshing sound createdby the turbulence at the anastomosis.The sounds should be continuous, onesound blending into the next.
Steal Syndrome
Steal syndrome is one reason fordecreased blood supply to the hand.Steal syndrome causes hypoxia andlack of oxygen to the tissues, resulting in pain that can range anywhere frommild to severe. The majority of casesof steal syndrome will resolve them-selves over several weeks as a result of collateral circulation development,but approximately 5% of patientswith AVFs will need immediate inter-vention due to severe symptoms(Henriksson, 2004). Patients with dia-betes with existing neuropathy andpatients with preexisting vascular dis-ease have the greatest risk for devel-oping the most severe case of stealsyndrome, Ischemic MonomelicNeuropathy (IMN), which is charac-terized by severe pain, sensory andfunctional loss, and weakness in thedistal extremity (Schanzer & Eisenberg,2004).In steal syndrome, the extremitywill be cold, capillary refill willdecrease, and the radial artery willnot be palpable. If not treated, ulcerformation will occur with the possibil-ity of amputation. Nurses can per-form the Allen Test to check for arter-ial circulation of the hand (see Figure2). This is done by compressing boththe radial and ulnar arteries simulta-neously while having the patient openand close the hand, allowing theblood to drain via the venous system
 Improving ArteriovenousFistula Cannulation Skills 
Figure 1Fistula First Outcomes Dashboard
November-December 2005 
Vol. 32, No. 6 
causing the hand to blanch. Havethe patient open the hand, palm up,and release one of the arteries, evalu-ating how fast refill occurs to thehand. Repeat the procedure again,this time releasing the other arterywhile timing the refill. Refilling of lessthan 3 seconds is considered a nega-tive test and indicates there is ade-quate blood flow in the palmer arch(Beathard, 2003). A very slow refillshould alert the multidisciplinaryteam to develop a plan for accessplacement, if one is not already inplace, or a revision of the current access, particularly if symptoms arepresent. Typically, grafts and upperarm fistulae are responsible for most of the cases of steal syndrome.
The major vascular access prob-lem impacting our practice is venousstenosis. Stenosis formation decreasesadequacy of dialysis from recircula-tion, can cause vessel wall damage,can prevent an access from maturing and can lead to clotting of the fistula.It is important to look for clues of venous stenosis. Edema is an indica-tion that there may be a problem withthe drainage system of the extremity,but it could also be caused by a cen-tral venous stenosis. Collateral circu-lation can form in the area near thecentral venous stenosis, with blue orpurple veins becoming visible in theupper arm and chest wall. When a stenosis is present, the continuoussound of the bruit will change to a choppy, distinctly separate sound. At the site of the stenosis, the bruit maybe higher pitched because of the nar-rowing or it may be louder than it isat the anastomosis. The pulse, whichis usually soft, will change its charac-ter and become a harsher, water ham-mer sound (Beathard, 2003).Recirculation studies are warrant-ed if some or all of the following cluesare present: a decrease in adequacyfrom month to month,decreasedblood pump speeds, increasing venous pressures, difficulty thread-ing needles or having blood squirt out around needles during cannula-tion, and/or increased bleeding times postdialysis.The process of what is occurring during recirculation can be illustrat-ed by comparing blood vessels to a highway. Visualize a four-lane high-way with an accident that closes twolanes so that the traffic will have tomerge into the open two lanes. Not only does this slow the traffic down,but also causes the traffic to back up.The same scenario applies to a veinthat has a stenosis present. Theblood will be slowed down on thesides where the stenosis is present and will have to merge with thefaster moving blood, which willcause turbulence as well as a back upof blood into the fistula. Because theblood pump is returning bloodthrough the venous needle at a con-stant speed, the “backed-up” bloodgets pulled into the arterial needleand into the extracorporeal circuit where re-cleaning or recirculationoccurs. Furthermore, this back up of blood creates increased pressurewithin the fistula, which will make it harder for the blood in the extracor-poreal circuit to get back into theblood vessel, thereby increasing thevenous pressure in the extracorpore-al circuit. As the machine pressureincreases, it may be necessary todecrease the blood pump speed toprevent hemolysis and/or vessel wall
Figure 2The Allen Test

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