Vascular 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
FRONT and BACK
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Do not put your Name on the test
When done turn in for your materials folder

Save Post-test and complete after class

AFTER CLASS

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

~~~

POST TEST
EVALUATION
CEU FORM
 Fill out name and address at top
 Enter 3.75 CEU Hours on CEU form (middle)
 Sign on bottom of form
 Save white copy - this is your proof of completion, you will not receive a certificate
 Turn in yellow copy to be sent to ANNA)

Disclaimer
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

AV Fistula
WHY 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

Loop/straight grafts: 3-4 weeks healing time

Always rotate cannulation sites to prevent pseudo-aneurysms

Cannulate at 45 angle

Confirm entry via blood flash-back

Trend venous pressures for stenosis monitoring

NewHeRO Vascular Access Device

Fistula

Artery

Graft
Artery

Vein
Artery
and vein
are
connected
creating
an
opening
between
the two

Vein

Artery and vein are connected

by a tube between the two
vessels

What is the HeRO device?

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).

SLEEVES 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 caps
Follow facility protocol!

Monitor closely Highest Risk of infection

S/S infection at exit site:
Redness, Swelling, Drainage

Sepsis:
Undocumented hypotension
Fever

Assessment

Why is today important?

Cannulation
technique
Cannulation
skill level

Improper cannulation
technique and skill level may
lead to:

premature access failure

patient fear or reluctance
How can we prevent premature
AVF access failure?
o Good technique
o Assessment of A-V Fistula
prior to cannulation
o Skill level of cannulator

Staff
turnove
r

Infection

Fistula
Development
Adequate Blood
Flow

Needle
Placement

A-V
Direction

Fistula Maturation
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

NKF-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/DOQI
Preferred

Assessment
Best Tool/Technique?
Look

Listen

Feel

Do you perform a physical exam of your patients access

before each treatment?

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

Feel:

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

Stenosis
A narrowing of the vessel

Normal

Narrowing

Clotted

Strong pulsation felt during palpation of the fistula during the assessment
indicates stenosis
Thrill/Bruit

Pulsatile

Pressure

Collapsed - With Elevation

Dilated

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 postdialysis
Elevated venous pressure
(frequent alarms)
Excessive negative pre
pump 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

KDOQI Guidelines 2006

(CPG 5.6.1)

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 Guidelines
Skin-Preparation
Technique for
Permanent
AV Accesses
A clean
technique for
needle
cannulation
should be used
for all
cannulation
procedures
(evidence)

1. 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.

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 following your
facilitys policy and procedure

Needle site

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

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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

Feeling
Palpate access
Gently compress access
midpoint
Arterial inflow will
pulse with flow
Venous outflow will have
diminished or no pulse

Listening
Auscultate access
Gently compress access midpoint
Arterial inflow will have pulsatile sound
Venous 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 the
aneurysm, causing elevated back pressure

17

Risk of Rupture

Aneurysm showing skin

breakdown, color changes, large
wound.

Photo courtesy of Rick Luscombe

Risk of Rupture
A 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 15gauge 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 accept
the 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

21

Patient Anxiety
Cannulation 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 nonbackeye

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 Fistula

The angle is from the skin to the
needle hub

2035 angle of insertion depending on the depth of

the access

Fistula needle/wings are the extension of your

hands and fingers
Careful not to touch needle with
gloves/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

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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ThreePoint
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 any
Intervention
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

29

Tracking Trending
Adverse 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

31

References
KDOQI Guidelines for Vascular Access
National 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 20082009\ Fistula Cannulation Training

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