On Course With CannulationOn Course With Cannulation

Lynda K. Ball, RN, BSN, CNNQuality Improvement CoordinatorNorthwest Renal Network

Under contract with the Centers for Medicare & Medicaid Services (CMS), contract #500-03-NW16.

Why Cannulation Training?Why Cannulation Training?

• Fistulae are technically more challenging than grafts

• High staff turnover rate = more inexperienced staff

• Seeing more AV Fistulae

• Are you using Best Demonstrated Practices?

Assessment

of

the

dialysis

access

InspectionInspection

• Redness • Drainage Infection• Abscess

• Skin color Central • Edema or• Small blue outflow

or purple veinveins stenosis

• Hands:ColdPainful StealNumb Syndrome

• Fingers: Discolored

• Prior cannulation sites

• Collateral/accessory veins

PalpationPalpation

TemperatureWarmth = possible infectionCold = decreased blood supply

ThrillNormally only present at the anastamosis.A thrill can be felt at a major stenosis.

PalpationPalpation

Vein Diameter

Feel the entire length of the AVFEvaluate for needle site selectionCheck for flat spots – you can seea stenosis and feel its thrillEvaluate if new AVF is ready to cannulate

AuscultationAuscultation

Bruit

Listen every treatment Changes in characteristics:

discontinuoushigh-pitchedlouder-pitched

Determine direction of flow

Causes of StenosisCauses of Stenosis

• Turbulence

• Aneurysm and pseudoaneurysm formation

• Needle stick injury to vessel wall

Checking for StenosisChecking for Stenosis

• Squeeze the kidney with your arm hanging down by your side and observe vein filling.

• Raise arm overhead and observe vein for collapse.

Central Vein StenosisCentral Vein Stenosis

Physical Findings of Venous StenosisPhysical Findings of Venous Stenosis

PARAMETER NORMAL STENOSIS

Thrill Only at the arterial anastamosis

At site of stenotic lesion

Pulse Soft, easily compressible

Water-hammer

Bruit Low pitchContinuous

Diastolic & systolic

High pitchDiscontinuousSystolic only

G.A. Beathard, MD, PhD

Clinical Indicators of StenosisClinical Indicators of Stenosis

• Clotting the system 2 or more times/month• Difficult needle placement• Persistently swollen arm• Increased machine pressures• Difficulty achieving hemostasis post dialysis• Decreased blood pump speeds• Decreased KT/V or URR.

Steal SyndromeSteal Syndrome

What is Steal Syndrome?What is Steal Syndrome?

• Decreased blood supply to the hand.• Causes hypoxia (lack of oxygen) to the

tissues of the hand resulting in severe pain.

• Neurologic damage to the hand can occur.

• Without oxygen, tissue dies and necrosis occurs.

Is Steal Syndrome Serious?Is Steal Syndrome Serious?

• Necrotic tissue cannot be “fixed” – it must be removed (amputated).

• This places patients at risk for infection.• Infection increases their risk for

hospitalization.• Hospitalization increases their risk for

death!

The Allen Test The Allen Test (negative)(negative)

PreparationPreparation

forfor

CannulationCannulation

Skin PreparationSkin Preparation

• The patient should wash their access with antibacterial soap before coming to their chair.

• Staph is the leading cause of infection in dialysis patients (CDC).

Proper cleansing techniqueProper 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.

Says Who? Says Who?

K/DOQI SAYS

•Guideline 14: 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 (e.g., 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 2-3 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.

A Word About AnestheticsA Word About Anesthetics

• Intradermal lidocaine can cause scarring (keloid formation in some patients) and vasoconstriction.

• Ethyl chloride – spray arterial site, prep skin, then insert needle immediately. Repeat for venous site.

• Topical anesthetic creams (EMLATM and less-n-painTM) must be applied to the access, then wrapped with saran wrap one hour prior to dialysis. Patient washes off at dialysis.

ThreeThree--Point TechniquePoint Technique

• Stabilize vessel for both grafts and fistulas.• Guide to ensure needle is in the center of the

access.• Pull the skin taut to allow easier needle insertion.• Compresses the nerve

endings, blocking painsensation to the brainfor approximately 20seconds.

Angles of EntryAngles of Entry

Rule of Thumb:

20-35o angles for fistulae

• 45o for grafts

Reality:

Not every access fits the Rule of Thumb.

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

ProblemsProblems

associatedassociated

withwith

dialysisdialysis

Hemolysis Hemolysis -- Arterial Pressure Arterial Pressure

• The blood is removed from the patient by a negative pulling pressure.

• Arterial pressures > -260 mmHg cause hemolysis. Reduce blood pump speed until pressure falls below this threshold. Notify MD that flow is not attainable.

• Larger bore needles can reduce pressure, if available.

AneurysmAneurysm

• Caused by sticking needles in the same general area.

• Cause stenosis formation because of turbulence

Photo courtesy of P. Cade

“One“One--sitesite--itis”itis”

• “One-site-itis” occurs when you stick the needle in the same general area, day after day.

• Causes aneurysm and stenosis formation.

Vascular Access

Area puncture technique aka “one-site-itis”

Thrombosis in AV FistulaThrombosis in AV Fistula

• Early cause:*surgical*technical issues

• Late causes:* poor blood flow*hypotension*hypercoagulability*patient compressing while sleeping

Clamps Clamps -- Holding SitesHolding Sites

• Clamps should not be used – no way to adjust pressure properly.

• Compression of the vessel along with hypotension can cause the access to clot off.

• Patients and/or family need to be taught to hold sites, otherwise, staff should hold.

Bruising Bruising -- Holding SitesHolding Sites

• If bruising occurs, the surface site has clotted, but the needle hole in the vessel wall has not.

• Need to hold sites longer.

• Use two fingers per site.

Flipping NeedlesFlipping Needles

• Historically, we flipped all needles because we did not have backeye needles.

• Causes enlargement of the entrance hole which allows blood to seep out around the needle during dialysis.

• Can cause coring of the access, requiring surgical closure of the hole.

• If cannulation technique is correct, rarely is there a need to flip needles.

DifferentDifferent

CannulationCannulation

TechniquesTechniques

Buttonhole Buttonhole ––

The oldThe old

becomesbecomes

newnew

again!again!

Facts About ButtonholeFacts About Buttonhole

• Used in Europe for over 25 years.

• First used on a patient with a limited area for cannulation.

• For native AV Fistulas only.

• Once called the “Constant-Site” method.

• Dr. Kronung renamed it the “ButtonholePuncture Technique.”

Facts About Buttonhole Facts About Buttonhole (cont)(cont)

• A comparison between “Rope Ladder” and “Constant-Site” techniques was done over 10,000 dialyses.

• “Constant-Site” Technique had:

* Fewer infections* Fewer infiltrations* Insertion easier - usually in less than 10 seconds* Fewer missed sticks* Fewer complications

*10-fold in hematomas* Less pain – can eliminate anesthetic

Twardowski 1979

Buttonhole TechniqueButtonhole Technique

• Sticking the same site using the same angle and depth every time.

• This technique has not been shown to cause aneurysm formation.

Constant site technique

aka Buttonhole technique

Vascular Access

Buttonhole ConsiderationsButtonhole Considerations

• Requires the same cannulator until the track is formed (~ 8 sticks, ~12 for diabetics).

• Scab removal: Most critical issue related to buttonhole cannulation.

• Use a cannulation log for each needle.

• Change to blunt needles once the track is formed – prevents track from being cut.

Buttonhole Barriers to SuccessButtonhole Barriers to Success

• Heavily scarred accesses from: multiple problematic needle sticks, long-lived fistulae or lidocaine use.

• Large amounts of subcutaneous tissue.

• Stenosis present – buttonholes will not improve clearances on a stenotic access.

• Not having the same cannulator during track formation.

Buttonhole Cannulation LogButtonhole Cannulation LogDate S/B Ga QB Art Pres URR Comments and/or complications

#1#2#3#4#5#6#7#8#9#10#11#12#13#14#15

Date S/B Ga QB Ven Pres URR Comments and/or complications#1#2#3#4#5#6#7#8#9#10#11#12#13#14#15

Document all of the above each treatment:S/B=Sharp or Blunt needle, Ga=Needle Gauge, QB=Blood flow rate. In the comments section, please give details of stick (i.e., direof needle, ease of stick, outcome and patient reaction. 1 page for each needle site. A drawn or photographed picture of the patient'access is to accompany this log. It should have needle sites drawn on it and the direction of flow. Revise to show new needle sites

Developing a ButtonholeDeveloping a Buttonhole

Developed Buttonhole SitesDeveloped Buttonhole Sites

Photo courtesy of V. Muchow Photo courtesy of J. Weintraub

CannulatingCannulating

aa

NewNew

AV FistulaAV Fistula

Cannulating a New AVFCannulating a New AVF

• Must have a physician’s order to cannulate.

• Must have an experienced, qualified staff person who is successful with all types of accesses – rating system.

• Always use a tourniquet or some form of vessel engorgement technique (e.g., staff or patient compressing the vein).

Cannulating a New AVF Cannulating a New AVF (cont)(cont)

• Check to see if heparin dose has been changed (decrease by half to prevent excess bleeding - opinion).

• Use 17-gauge needles initially.

• If patient has a catheter, use one limb and one needle.

1 Needle 1 Needle -- Arterial or Venous?Arterial or Venous?

ARTERIALIf an infiltration occurs, blood is not being forced into tissue.Pre-pump AP tells us if the AVF has good flow.Lower risk of complications

VENOUSTo help engorge the fistulaInfiltration with the blood pump force can cause massive hematomaNo use until hematoma resolves

Infiltrations in New AVFInfiltrations in New AVF

• If the fistula infiltrates, let it “rest” until the swelling is resolved (Guideline 9).

• If the fistula infiltrates a second time, wait another two weeks (or longer if the swelling has not resolved).

• If the fistula infiltrates a third time, the RN should notify the surgeon.

Catheter RemovalCatheter Removal

• Once the patient has had six successful treatments, the RN should get an order to have the catheter removed.

• Successful = getting two needles in, no infiltrations, and reaching the prescribed blood flow rate for six treatments.

Facts to PonderFacts to Ponder

• The average life expectancy of a patient with renal failure is 5.5 years.

• The average life expectancy of a hemodialysis access is < 1 year!

• Access type is a major determinant of patient and financial outcomes.

• Most vascular access-related morbidity and costs are due to grafts and catheters.

USRDS 2003 Annual Data Report

ConversionConversion

ofof

GraftsGrafts

to AV Fistulaeto AV Fistulae

“Sleeves Up” Protocol“Sleeves Up” Protocol

• Converting an AV graft to an AV fistula before AV graft fails.

• Place a light tourniquet just below the shoulder.• If vessel appears to be well developed, order a

fistulogram - all the way to the heart. (MD order)• If the fistulogram is normal, cannulate the

outflow vein with the venous needle for 2 consecutive treatments. (MD order)

• If no problems with these cannulations, patient should be scheduled for a surgical conversion.

Dr. Larry Spergel

In Closing…In Closing…

• We will be seeing more AV fistulae, and facility staff should seek to improve their skills in order to maintain patients’ accesses.

• As a cannulator of vascular access for hemodialysis patients, strive to be the best you can be.