On Course With Cannulation
Lynda K. Ball, RN, BSN, CNN
Quality Improvement Coordinator
Northwest Renal Network
In collaboration with
Southeastern Kidney Council, Inc.
Under contract with the Centers for Medicare &
Medicaid Services (CMS), contract #500-03-NW16.
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
1
Inspection
• Redness
• Drainage
• Abscess
• Skin color
• Edema
• Small blue
or purple
veins
Infection
• Hands:
Cold
Painful
Numb
• Fingers:
discolored
Steal
Syndrome
Central
or
outflow
• Prior cannulation sites
vein
stenosis
Palpation
Temperature
9 Warmth = infection
9 Cold = decreased blood supply
Thrill
9 Normally a thrill is present at the
anastamosis, and disappears when you
manually occlude the AVF.
9 If a thrill remains = accessory veins
9 Thrill can be felt at the site of a stenosis
Palpation
Vein Diameter
9 Feel the entire length of the AVF
9 Evaluate for needle site selection
9 Check for flat spots – you can see
a stenosis and feel its thrill
9 Evaluate if new AVF is ready to
cannulate
2
Auscultation
Bruit
9 Listen every treatment
9 Changes in characteristics:
discontinuous
high-pitched
9 Determine direction of flow
Types of Stenoses
• Juxta-anastomotic
(inflow)
Central vein
• Outflow
Outflow
• Central vein
Inflow
Causes of Stenosis
• Turbulence
• Aneurysm and pseudoaneurysm
formation
• Needle stick injury to vessel wall
3
Aneurysm
• Caused by
sticking needles
in the same
general area.
• Cause stenosis
formation
because of
turbulence
Photo courtesy of P. Cade
Checking 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.
Physical 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 pitch
Continuous
Diastolic & systolic
High pitch
Discontinuous
Systolic only
G.A. Beathard, MD, PhD
4
Clinical Indicators of Stenosis
•
•
•
•
•
•
•
Clotting the system 2 or more times/month
Difficult needle placement
Persistently swollen arm
Difficulty achieving hemostasis post dialysis
venous pressure
blood pump speeds, KT/V and URR
Recirculation
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
• Without oxygen, tissue dies and
necrosis occurs
• Grafts and upper arm fistulas cause the
most steal
5
Steal - High Risk Individuals
• Steal Syndrome resolves itself in 95% of
the cases due to the development of
collateral circulation
• Those 5% who need intervention are:
~Diabetics with neuropathy
~Patients with peripheral vascular
disease
• Neurologic damage to the hand can occur
The Allen Test (negative)
Preparation
for
Cannulation
6
Skin Preparation
• The patient should
wash their access
with soap and water
or alcohol-based
product before
coming to their
chair.
• Staph is the leading
cause of infection in
dialysis patients
(CDC).
Proper 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?
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:
ƒ
Alcohol has a short bacteriostatic action
time and should be applied in a rubbing
motion for 1 minute immediately prior to
needle cannulation.
ƒ
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.
ƒ
Clean gloves should be worn by the dialysis
staff for cannulation. Gloves should be
changed if contaminated at any time during
the cannulation procedure.
ƒ
New, clean gloves should be worn by the
dialysis staff for each patient.
7
A Word About Anesthetics
• Lidocaine causes
•
scarring, keloid
formation and vasoconstriction.
• Ethyl chloride – spray
arterial site, prep,
then insert needle.
Repeat for venous
site. NOT sterile.
EMLA cream applied by
the patient to the
access, then they wrap
with saran wrap. Works
by time of contact, not
by amount applied.
Too much may cause
vasodilation approx. 3
hours after application.
Three-Point 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 pain
sensation to the brain
for approximately 20
seconds.
Problems
associated
with
dialysis
8
Hemolysis - 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.
• The patient may need larger bore
needles for their treatment.
“One-site-itis”
• “One-site-itis”
occurs when you
stick the needle in
the same area, day
after day.
Vascular Access
Area puncture technique
aka “one-site-itis”
• Causes aneurysm
and stenosis
formation.
Clamps - Holding 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.
9
Bruising - Holding 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 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.
Different
Cannulation
Techniques
10
The Buttonhole Technique
Another technique for
inserting needles into
native AV fistulae
Facts About Buttonhole
• Used in Europe and Japan 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 “Buttonhole
Puncture Technique.”
Facts About Buttonhole (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
11
Buttonhole Technique
• Sticking the same
site using the same
angle and depth
every time.
Vascular Access
Constant site technique
aka Buttonhole technique
• This technique has
not been shown to
cause aneurysm
formation.
Buttonhole
• Requires the same “sticker” until the track
is formed (~8 sticks, ~12 for diabetics)
• Determine the best two sites on the
access = good arterial and venous
pressures, good blood pump speeds, and
least likely areas for infiltrates
Buttonhole
• Scab removal the most important step to
prevent infection
• The Buttonhole Technique requires removing
the scab before cannulating.
• Moistening the scabs makes them easier to
remove.
• The scab will look like a mushroom, with a
cap and stem.
12
Removing the Scab
• Changing to blunt needles once the
track is formed helps to prevent cutting
of the scar track/tunnel.
• Oozing will occur if the track/tunnel is
cut after heparinizing the patient.
Do’s and Don’ts
of Scab Removal
• Don’t flip the scab off with
the needle you will use for
cannulation – this
contaminates the needle.
• Don’t use a sterile needle
– you could cut the
patient’s skin and you will
need a sharps container
nearby.
• Don’t let patients pick off
scabs.
• Do use either:
~aseptic tweezers;
~soak two 2 x 2s with
sterile saline and lay
over the scabs;
~moisten 2 x 2s with
alcohol-based gel; or
~have patient tape
alcohol squares over
sites prior to dialysis.
Needles – sharp and blunt
13
Changing to blunt needles
• This will be individual to each patient, but you
want to look for these things:
¾ Can you visualize a round hole?
¾ Does it look well-healed?
¾ Has the sharp needle been going in
smoothly?
• Do not use excessive force when changing to
blunt needles.
• You may need to rotate the needle back and
forth while advancing down the track.
A Developing Buttonhole
ŠA ridge is starting
to develop.
ŠA hole is starting
to develop.
ŠThis site is not yet
ready for a blunt
needle.
Developed Buttonhole Sites
14
Barriers to success
• Heavily scarred accesses from:
¾ multiple problematic needle sticks
¾ long-lived AV fistulae
¾ lidocaine use
¾ keloid formation
• Large amount of subcutaneous tissue
• Not dedicating one staff person for
cannulation during the track formation
Cannulating
a
New
AV Fistula
When is an AVF Mature?
• Nurse should look, listen and feel the new AVF
every dialysis treatment and document
• Start access exercises 1 week post-op
• Soft/pliable
firm/springy resistance
• Diameter of vessel increasing (2mm
4-6 mm)
• Experienced dialysis nurses have an 80%
success rate identifying AVF maturity (Robbin et al,
2002)
• Post-op visit at 4 weeks – if there is no progress
there needs to be follow-up then (Beathard, 2003)
15
Cannulating 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 (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 - Arterial or Venous?
ARTERIAL **
VENOUS
¾ If an infiltration occurs, ¾ To help engorge the
blood is not being
fistula
forced into tissue.
¾ Infiltration with the
blood pump force can
¾ Pre-pump AP tells us
cause massive
if the AVF has good
hematoma
flow.
¾ No use until
¾ Lower risk of
hematoma resolves
complications
** Recommended by K/DOQI
16
Infiltrations 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 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.
Conversion
of
Grafts
to AV Fistulae
17
“Sleeves Up” Protocol
• Converting a graft to a fistula before graft fails
• If vessel appears to be well developed, order a
fistulogram - all the way to the heart. (MD order)
• Place a light tourniquet just below the shoulder
• 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…
• 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.
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