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 Be honest, dont share answers 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 Artery and vein are connected creating an opening between the two

Graft Vein

Artery

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?

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
Cannulation skill level

Cannulation technique

Infection

Staff turnove r

Fistula Development Adequate Blood Flow A-V Direction

Needle Placement

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?

L
Compare extremities Color change

K:

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

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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

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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

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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

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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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