VASCULAR ACCESS IN HEMODIALYSIS

Objectives
At the end of this section the staff will be able to,
 Differentiate different types of vascular access
 Assess the A/V fistula
 Cannulate the fistula or graft.
 Methods of cannulation
 Complications

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THERE ARE 3 TYPES OF VASCULAR ACCESS

Arteriovenous fistula (AVF)

Prosthetic arterio-venous graft (AVG)

Catheter

Temporary double lumen catheter

Permanent Catheter
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 Arteriovenous (AV) Fistula
 A fistula is created direct connecting of an artery to a
vein. Once the fistula is created it is a natural part of the
body.
 It can take weeks to months before the fistula matures
and is ready to be used for hemodialysis

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Advantages
 It has a lower risk of infection than grafts or catheters
 It has a lower tendency to clot than grafts or catheters
 It allows for greater blood flow, increasing the effectiveness
of hemodialysis as well as reducing treatment time
 It stays functional for longer than other access types; in
some cases a well-formed fistula can last for decades
 Fistulas are usually less expensive to maintain than
synthetic accesses

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 BEST TOOL/TECHNIQUE? FOR
ASSESSMENT…………………
Physical Exam
Look, Listen, and Feel Using;

Eyes

Ears

Fingertips
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 INSPECTION
Look for
Changes compared to opposite extremity
Skin color/circulation
Skin integrity
Edema
Drainage
Vessel size/cannulation areas
Aneurysm
Hematoma
Bruising 7
 PALPATION
Temperature Change

Warmth = possible infection

Cold = decreased blood supply

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 PALPATION
Thrill
Palpation can be started at the anastomosis
Thrill diminishes evenly along access length
Change can be felt at the site of a stenosis; becomes
“pulse-like” at the site of a stenosis
Stenosis may also be identified as a narrowed area
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 AUSCULTATION

Listen for Bruit

Listen to entire access every treatment
Note changes in sound characteristics (bruit):
A well-functioning fistula should have a continuous,
machinery-like bruit on auscultation
An obstructed (stenotic) fistula may have a
discontinuous and pulse-like bruit rather than a
continuous one—and also may be louder and high-
pitched or “whistling”
Louder at stenosis than at anastomosis
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 NEEDLE GAUGE

17-gauge needle is strongly recommended for initial

cannulation
A fistula may appear and feel ready to cannulate, but the
vessel wall may still be fragile and unable to tolerate the
needle puncture
The smaller needle gauge helps to decrease injury to the
vessel and prevents a large infiltration, hematoma,
compression of the vessel, and possible clotting of the AVF
should any cannulation complication occur (ie, infiltration)
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MATCH NEEDLE GAUGE TO BLOOD FLOW
RATE (BFR)
Needle Gauge Maximum BFR

17-gauge < 300 mL/min

16-gauge 300-350 mL/min

15-gauge 350–450 mL/min

14-gauge > 450 mL/min

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 USE BACK-EYE NEEDLES

Non–back-eye
Back-eye opening allows needle—for
blood intake from both venous use only
sides of the needle; can
be used as arterial or
venous needle

Arterial needle Venous needle

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BACK-EYE NEEDLE FLOW

Allows blood to
enter or exit from
both the bevel and back-eye

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 NEEDLE DIRECTION

Always cannulate the venous needle with the

direction of the blood flow

Always cannulate the arterial needle cannulation

toward the blood inflow or with the blood

outflow
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 Needle Direction
Venous
needle
directed
back
toward the
heart
Arterial
needle
directed
toward the
arterial
anastomosi
s
(retrograde)

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 Needle Direction
Venous
needle
directed
back
toward the
heart

Arterial
needle also
directed
back toward
the heart
(antegrade)

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 “WET” NEEDLE

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 CANNULATION TECHNIQUES
Site-Rotation Buttonhole
Also known as: Also known as:
Rope ladder Constant-site
Rotating sites Same-site

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 SITE-ROTATION TECHNIQUE

Cannulation sites are rotated up and down the

AVF to use its entire length
Classic technique used in most dialysis centers

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 Venous
site-rotation
cannulation
sites

Proper site-rotation
cannulation technique with Arterial
site-rotation
rotation of both venous and
cannulation
arterial needle sites
sites

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 Poor venous
site rotation

Poor arterial
site rotation
Improper site-rotation
cannulation technique with
rotation of both venous and
arterial needle sites

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 THREE-POINT TECHNIQUE

Use of tourniquet should be mandatory

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) 23
“L” TECHNIQUE

Hold thumb and index

finger as an “L”

Thumb holds
skin taut over fistula
Index finger stabilizes and engorges
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 NEEDLE REMOVAL

Apply gauze dressing without pressure

Remove needle at insertion angle
Apply pressure with 2 fingers
Do not use excessive pressure
Hold for 10–12 minutes, no peeking
Use stethoscope to check for bruit after applying dressing
to stick site

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 NEEDLE REMOVAL

Apply adhesive bandages

Dispose of needles in biohazard sharps container
per guidelines specified in the Occupational Safety
and Health Act (OSHA)

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 POST-TREATMENT HEMOSTASIS

Pull needle completely from the vein before pushing down

on the needle site
Hold direct pressure for 10 minutes without “peeking”—no
exceptions
Do not use clamps unless absolutely necessary!

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NEEDLES—SHARP AND BLUNT

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COMPLICATIONS

95
 BLEEDING

Bleeding during treatment (oozing around needle or

infiltration) = fragile vessel wall or back wall penetration;
don’t flip the needles

Bleeding post–needle removal = fragile vessel wall or

needle trauma or inadequate pressure at puncture sites

Review needle-removal technique. Improper pressure with

needle withdrawal = vessel damage 30
 BLEEDING

A pattern of prolonged bleeding post–needle removal

may indicate stenosis or clotting disorder. Evaluate bleeding after
20 minutes

Educate patients about post-treatment hemostasis and what to

do at home should the needle site re-bleed
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INFILTRATION = HEMATOMA

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PREVENT POST-DIALYSIS INFILTRATIONS

Apply gauze without pressure

Remove needle at insertion angle
Apply pressure with 2 fingers
Hold pressure 10–12 minutes

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 HOW TO PREVENT INFILTRATIONS

Check for flashback and aspirate

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

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 POST-CANNULATION BRUISING AND
HEMATOMA

If bruising or hematoma occurs

after dialysis, the surface skin site
has sealed but the 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
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 POOR FLOW

May be due to location or position of needle(s)

May need to change direction of arterial needle
If poor flow persists after next session despite changing
needle locations, refer to surgeon for evaluation and
possible treatment options
Use tourniquet for cannulation only!
Do not leave in place for entire treatment!!!

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 STENOSIS

Most common complication

Causes:
IV, CVC, lines
Surgery to create AVF
Aneurysms
May be caused by the back pressure associated with
stenosis
Needle-stick injury
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 STENOSIS

Frequent cause of
early fistula failure
Juxta-anastomotic Stenosis

stenosis most
common
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 DISTENDED, OBSTRUCTED LEFT
SHOULDER VEINS INDICATIVE OF
CENTRAL-VEIN STENOSIS

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 THROMBOSIS

Surgical/technical problems
Preexisting anatomic lesions (eg, old IV injury)
Premature use
Poor blood flow
Hypotension
Hyper-coagulation
Fistula compression
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 INFECTION

AV fistulas have lowest risk of infection of any vascular

access type. However…
Each pre- and post-treatment exam should include:
Checking for signs/symptoms of infection, including:
Changes of skin over access area
Redness
Increase in temperature
Swelling, hardness
Drainage from incision, needle sites
Tenderness or pain 41
 STEAL SYNDROME/ISCHEMIA

Steal syndrome is a constellation of symptoms related to

ischemia (inadequate blood supply to the hand) caused by
the AVF “stealing” blood away from the extremity

Steal causes hypoxia (lack of oxygen) to the tissues of the

hand, resulting in severe pain and identified by nail bed
discoloration, a cool hand, and a weak or absent pulse

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“CLAW HAND” CONTRACTURE FROM
STEAL SYNDROME

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Reference
 www.aakp.org
 www.nkdep.nih.gov
 https://www.youtube.com/watch?v=O_Z75Bjhob
M

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