TECHNIQUE ON CANNULATION OF FISTULA AND GRAFTS

Access Physical Examination

Exam Steps Fistula (Normal) AVG (Normal) Stenosis or Poor Maturation (Abnormal) >Fistula with multiple venous outflow veins > Look for a narrowing of the outflow vein or aneurysms. > Dilated neck veins or small surface collateral veins Infection or Steal Syndrome (Abnormal INFECTION > Redness, Swelling, Broken Skin, Drainage, Induration.

LOOK

>Well developed vein outflow >No dilated areas or aneurysm formation >Areas of straight vein >Vessel partially collapses when arm is elevated

>Uniform sized graft >No irregular areas or aneurysms

STEAL SYNDROME >Discoloration of the access hand >Check for nail beds and hands

Access Physical Examination

Exam Steps Fistula (Normal) AVG (Normal) Stenosis or Poor Maturation (Abnormal) High pitch discontinuous systolic only Infection or Steal Syndrome (Abnormal STEAL SYNDROME: Fistula may have a very strong bruit

LISTEN

Low pitch continuous diastolic & systolic

Low pitch continuous diastolic & systolic

Access Physical Examination

Exam Steps Fistula (Normal) AVG (Normal) Stenosis or Poor Maturation (Abnormal) Infection or Steal Syndrome (Abnormal

FEEL

Thrill at the arterial anastomosis and the entire outflow vein

Thrill strongest at the arterial anastomosis but must be felt at the entire graft

Fistula & Graft: Pulse at the site of the stenotic lesion. Pulse has a water hammer feel

INFECTION: > Warm to touch, Swelling

STEAL SYNDROME: > Feel bilateral limbs and Graft: Feels compare them mushy or (temperature, irregular in grip strength, shape. Can be ROM and a site of complaints of aneurysm pain)

Skin Preparation Techniques

1.

Locate, inspect and palpate the needle cannulation sites prior to skin prep.

2.

Wash access with antibacterial soap and water

Cleanse the skin by applying 2% chlorhexidine gluconate/ 70% isopropyl alcohol/ and or 10% povidone iodine.

3.

Technique for Mature AVF Cannulation

1. 2. 3.

4.
5.

6.

After skin prep Apply tourniquet Pull skin taut to the opposite direction of needle insertion For easy palpated vessel, use a 25% angle of insertion bevel up Once the vessel has been penetrated, lower the angle of the needle & advance the needle slowly Tape the needle at the same angle with the angle of insertion.

Technique for AV Graft Cannulation

1. 2.

3.

After skin prep, pull skin taut in the opposite direction of the needle insertion. Avoid excessive pressure to cannulation site. Use 45 degrees angle of insertion. Once the vessel have been penetrated:

4.

Tape the needle at the same angle as the needle insertion.

Advance the needle slowly with cutting edge facing up For a deep, hard to palpate AVG rotate the access of the needle to 180 degrees and advance slowly.

Complications of vascular Access

Venous Catheter (IJ, SC, Femoral)

AV Grafts

Most likely to develop infection and clotting problems that may require medication and catheter removal or replacement.

AV Fistulas

May develop low blood flow which can be an indication of clotting or narrowing of the access. May require surgery such as angioplasty. Infection and low blood flow are less common but must still be monitored.

CANNULATION TIPS
A fistula that only works with a tourniquet in place is still underdeveloped, usually because of inflow stenosis. The combined use of the new fistula and bridge vascular access may be necessary until the fistula is well developed. Cannulation performed at a nonturnover time may provide more time for the cannulation procedure. A needle with a back eye should always be used for the arterial needle.

Apply a tourniquet to the access arm. After disinfecting the access site per unit protocol, carefully cannulate the fistula, using a 25 insertion angle. When blood flash is observed, flatten the angle of the needle, parallel to the skin, and advance slowly. When the needle is in the vessel, remove the tourniquet and tape the needle securely per unit protocol. Assess for adequate blood flow by alternately aspirating and flushing the needle with a syringe. Assess carefully for signs of infiltration, ie, pain, swelling, or discoloration. Repeat steps 1 to 5 for the second needle.

Cannulation

Infiltrations, Problems, and Tips

Infiltrations with the cannulation can occur before, during and after dialysis. Monitor closely for signs and symptoms of infiltration.

The decision to leave the needle in place and cannulate another site may be appropriate.
Immediately applying ice can help decrease:
o Pain o Size of infiltration o Bleeding time

 Use caution when taping needles. Avoid lifting up on the needle after it is in the vein. If the fistula is infiltrated, it is best to rest the fistula for at least 1 treatment. If not possible, the next cannulation should be above the site of the infiltration. If the patient still has a catheter in place, restart use of the fistula with 1 needle and advance to 2 needles, larger needle size, and greater BFRs as the access allows.

 Proper needle infiltrations.

removal

prevents

postdialysis

o Apply the gauze dressing over the needle site, but do not apply pressure. o Carefully remove the needle at approximately the same angle as it was inserted. o Do not apply pressure to the puncture site until the needle has been completely removed

Patient Education Basics

All patients should be taught how to:

Compress a bleeding access Proper washing of skin over the access everyday and before HD. Recognize s/s of infection Select proper methods of exercising fistula Palpate thrill/pulse daily and after any hypotension, dizziness, or lightheadedness. Listen for bruit if palpation for thrill is not possible.

Patient Education Basics

All patients should know how to:

Avoid carrying heavy items on the access arm or wearing occlusive dressing. Avoid sleeping on access arm Insist that staff rotate cannulation site each treatment Ensure that staff uses proper techniques in hooking and wearing gloves and mask for all access connections Reports signs and symptoms of infection or absence of bruit/thrill to the dialysis personnel.

Health Teaching for Patients Regarding their Vascular Access

Make sure your nurse or technician checks your access before each treatment. Keep your access clean at all times. Use your access site only for dialysis. Be careful not to bump or cut your access. Dont let anyone put a blood pressure cuff on your access arm. Dont wear jewelry or tight clothes over your access site. Dont sleep with your access arm under your head or body. Dont lift heavy objects or put pressure on your access arm. Check the pulse in your access every day.

BFR for Specific Needle Gauges

Gauge Gauge Gauge

17 BFR : 200-250ml/min 16 BFR : 250-350ml/min 15 BFR : 350-450ml/min

Gauge

14 BFR : >450ml/min

THANK YOU