Renal: Cannulation of an Arteriovenous Fistula / Graft – Doc #
Guideline and
Procedure
Cannulation of an Arteriovenous Fistula / Graft
Document Number:
Sites where Guideline and Procedure
applies:
All HNE facilities where a patient undergoes haemodialysis
Target audience:
Nephrology clinical staff, who provide care to haemodialysis
patients.
This document comprises part of the clinical information
package for care for Hemodialysis Dialysis patients.
Cannulation, Haemodialysis
Description:
Keywords:
Replaces Existing Guideline and
Procedure:
Yes
Registration Number(s) and/or name and
of Superseded Documents:
JHH Nephrology SWP N.3.9
Relevant or related Documents, Australian Standards, Guidelines etc:
 NSW Health Policy Directive 2007_079 Correct patient, Correct procedure, correct site
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf
 NSW Health Policy PD 2005_406 Consent to Medical Treatment
http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf
 NSW Health Policy Directive PD 2007_036 Infection Control Policy
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf
 National Kidney Foundation KDOQI Clinical Guidelines for Vascular Access (2006): Guideline 3
– Cannulation of Fistulae and Grafts and accession of Haemodialysis catheters and port
catheter systems. www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm
Prerequisites (if required):
Registered or Endorsed Enrolled Nurses who have been deemed
competent in the performance of haemodialysis
Procedure Summary:
This Guideline and Procedure sets out the steps to be followed when
cannulating fistulas and grafts in the hemodialysis patient. The procedural
components of the document such as, Preparation of patient, Preparation
of equipment, Technique, Cleaning up and Documentation are considered
mandatory.
Guideline Note :
This document reflects what is currently regarded as safe and appropriate
practice. However in any clinical situation there may be many factors that
cannot be covered by a single document and therefore does not replace
the need for the application of clinical judgment in respect to each
individual patient.
Date authorised:
Authorised by:
3rd June 2010
HNEAHS Renal Clinical Stream Leadership Group
Contact Person:
Kelly Adams – Renal Stream Coordinator
Contact Details:
02 490 48800
Review due date:
TRIM Number:
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OUTCOMES
1
To successfully cannulate a fistula and/or graft for the purpose of performing hemodialysis and
prolonging the life and patency of the fistula/graft
2
To minimize fistula/graft cannulation complications, ensure optimal patient care and decrease
the incidence of hospitalizations due to cannulation related incidences
ABBREVIATIONS & GLOSSARY
Abbreviation/Word
Definition
AVF
Arteriovenous fistula
AVG
Synthetic arteriovenous grafts
PPE
Personal Protective Equipment
CVC
Central Venous Catheter
GUIDELINE
An arteriovenous fistula is the surgical joining of an artery and a vein resulting in vein dilatation due
to the redirected blood flow. An arteriovenous graft is the surgical placement of a synthetic tube
between the artery and the vein and the graft material is where cannulation occurs (Ball, 2006).
Haemodialysis associated cannulation involves inserting two large bore steel needles into the
arteriovenous fistula or graft. One needle is used to take blood out of the patient and the other
needle is used to simultaneously return the filtered blood back to the patient. Blood flow needs to
be at least 200mls/minute for effective haemodialysis to occur.
A new arteriovenous fistula should not be cannulated until maturation is specified by the Vascular
Surgeon, Nephrologist or Vascular Access Nurse.
Vascular access related complications contribute to significant morbidity. Safe cannulation practise
is essential to minimise these complications and therefore provide optimal patient care and
vascular access care maintenance. Ultrasound guided cannulation enables real time visualisation
of the vascular anatomy of the patient’s fistula or graft and enhances accurate, safe cannulation
practises.
Due to length of time needed for appropriate application as well as recent clinical studies
(Daarouiche, Wall, Itani et al, 2010) it is recommended that 2% Chlorhexidine gluconate / 70%
isopropyl alcohol antiseptic be used for skin preparation as it has a rapid (30sec) and persistent
(up to 48hr) microbial activity on the skin. The solution should be applied using a back and forth
friction scrub for 30 seconds and then allowed to air dry (KDOQI, 2006).
It is recommended that when available, the nursing staff should use hand held ultrasounds to
improve visualisation of new vessels when first cannulated and for any ongoing difficult
cannulations to decrease the risk of trauma to the vessel.
Nursing Alert: Cannulated venous access and cannula connections must be visible at all
times and not be covered ie. Bed clothes
PROCEDURE
The procedure requires mandatory compliance.
Patient Preparation
It is mandatory to ensure that the patient has received appropriate information to provide informed
consent and, that patient identification, correct procedure and correct site process is completed
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prior to any procedure.
Note: If able patient should wash their access with antimicrobial soap and water before being
seated for treatment
Staff Preparation
It is mandatory for staff to follow relevant: “Five moments of hand hygiene”, infection control,
moving safely/safe manual handling, and documentation practices.
New fistula’s / grafts should be accessed by experienced staff only. The staff allocation for this
procedure should be in consultation with the Nursing Unit Manager or Team Leader of the shift.
If a patient is initiating onto dialysis the Renal Stream Clinical Protocol on Initiating Chronic Dialysis
takes precedent in blood flow rates to minimise risk of disequilibrium syndrome
Equipment Requirements











Alcohol hand gel
PPE
Dialysis Pack
Tape
AVF/AVG cannulas x 2 (select appropriate size)
Alcohol and Chlorhexidine solution (Must wait 60 seconds for the solution to dry (KDOQI
Guideline 3))
Normal Saline ampoules 10ml x 2 to flush cannulas
Local anaesthetic as prescribed
3ml syringe and 25g Magellan needle if local anaesthetic is required
Tourniquet (for AV fistulas, not for AV grafts)
Sharp disposal container
Procedure Steps for Cannulation
1. Identify correct patient, introduce yourself and explain procedure to patient.
2. For initial cannulation or post surgical revision of fistula or graft surgeon or Nephrologist
approval for cannulation is essential
3. Check for allergies to tapes or local anaesthetics, topical antimicrobial solutions
4. Instruct patient to wash their access site with antimicrobial soap and water
5. Wash your hands
6. Place tourniquet loosely on arm if AVF. Never use a tourniquet for an AVG.
7. Expose entire access limb and assess fistula for location, audible bruit (with stethoscope),
cannulation sites, pain, redness, bruising, oedema, exudate, capillary refill. Notify MO of
any concerns. In AVG roll fingers over the graft to determine location, width and depth
8. If available (and required) use hand-held ultrasound equipment for precise vascular access
visualization
9. Wash your hands
10. Prepare cannulation tray, chlorhexidine, 2 x 10ml Saline flushes, 2 x fistula cannula,
anaesthetic as prescribed, one 3ml syringe with magellan 25g needle if using local
anaesthetic (Note: topical anaesthetic must be applied 30 minutes prior to cannulations)
tapes, sharps container
Select appropriate needle size (refer to algorithm)
For new fistula 16g for three hemodialysis treatments and gradually increase to 15g as successful
cannulations achieved (Van Loon 2009)
Cannulating the new fistula with a CVC insitu
Insert arterial cannula only (decreases risk of infiltration) and use CVC for venous return for three
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successful cannulations
Then use fistula for venous return only for three successful cannulations
Then cannulate with arterial and venous cannula and arrange removal of CVC
11. Don PPE
12. Attend hand wash
13. DON gloves
14. Disinfect fistula/graft with Chorhexidine 2% and allow to dry for 1 minute before needle
insertion*
Alert: Repeat Prep if skin is touched by patient or staff after then skin prep has been
applied but prior to commencement of cannulation (KDOQI, 2006)
15. Select arterial cannulation site.
Needle Placement
2.5cm hub to hub if antegrade (with blood flow - facing venous anastomosis) /retrograde
(against blood flow – facing arterial anastomosis)
7.5cm hub to hub if antegrade/antegrade
Needle tip must be 4cm from anastomosis
16. Check cannula caps and clamps are secure to prevent blood leakage when inserting
needles
17. Pull skin taut and inject anaesthetic subcutaneously as prescribed. Withdraw plunger to
observe for blood return and ensure needle is not in the blood vessel. In the absence of
blood return, inject anaesthetic. If blood return evident reposition needle before injecting.
Repeat for venous site
18. Tighten tourniquet
19. Hold cannula in dominant hand and pull skin taut in opposite direction of needle insertion
20. Insert arterial cannula at 25 degree angle for fistulas and 45 degree angle for grafts with
bevel up, until flash back of blood is evident in tubing.
21. If no signs of resistance, pain or infiltration reduce angle of needle and advance into the
vessel.
22. Release the tourniquet
23. If blood flash back is not evident on cannulation but proper placement is suspected, release
the cap of the cannula to check for blood flow.
24. Secure cannula with tape across and under wings
25. Allow blood to prime cannula tube
26. Tighten cap and clamp cannula
27. Remove cap
28. Connect Saline syringe, unclamp cannula and draw back to remove air.
29. Flush to check for resistance and flow as well as patients pain rating.
30. Reclamp cannula
31. Repeat for second cannulation
32. Place platypus guards on cannula tubing
33. Commence haemodialysis but ensuring that pressures are checked
34. Dispose of PPE and equipment
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35. Document appropriately
Unsuccessful Cannulation
Remove needles at the same angle as the angle of insertion. Never apply pressure before the
needle is completely out. Apply pressure for 10 minutes with sterile gauze.
* Number of attempts
Two cannulation attempts by one nurse only for each needle site. Then seek assistance
from another cannulator.
If infiltration occurs, apply ice and rest for one week or until swelling or bruising resolved. If
required instruct patient to use appropriate ointment. If hemodialysis is essential recannulate above area of infiltration.
APPENDICES
Cannulation Flow Chart
Five Moments for Hand Hygiene
REFERENCES
Ball, L (2005) Improving Arteriovenous Fistula Cannulation Skills. Nephrology Nursing Journal
Nov-Dec 2005 Vol 35, No 6. P 1-7
Ball, L (2006) Determining Maturity of New Arteriovenous Fistula. Nephrology Nursing Journal
Mar-Apr 2006 Vol 33, No 2. P 1-2
Brouwer, D (1995) Cannulation Camp: Basic Needle Cannulation Training for Dialysis Staff.
Dialysis and Transplantation Vol 24, No 11. P 1-7
Darouiche, R.O., Wall, M.J., Itani, K.M.F., Otterson, M.F., Webb, A.L., Carrick, M.M., Miller, H.J.,
Awad, S.S., Crosby, C.T., Mosier, M.C., Alsharif, A. and Berger, D.H. (2010) Chlorhexadine
Alcohol versus Povidone Iodine for surgical site antisepsis. The New England Journal of Medicine,
362(1). p18-26.
Hand Hygiene Australia 2008: Five Moments for Hand Hygiene
National Kidney Foundation KDOQI Clinical Guidelines for Vascular Access (2006): Guideline 3 –
Cannulation of Fistulae and Grafts and accession of Haemodialysis catheters and port catheter
systems. www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm
Van Loon, M (2009) Cannulation practice patterns in HD vascular access. Journal of Renal Care
EDTNA
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Appendix 1
1. Cannulation of new fistula without CVC
Week 1
16g Needles
200 BFR
VP <160 mmHg
infiltration
If significant infiltration rest for 1
week before attempting
recannulation
Notify Nephrologist to discuss
urgency of hemodialysis and
vascular access
Absence
of
infiltration
Week 2
15g Needles
250-300 BFR
VP <160 mmHg
2. New fistula cannulation with CVC insitu
Week 1
16g Needles arterial access
CVC for venous return
200-250 BFR
Absence
of
infiltration
Week 2
15g needles venous return
CVC for arterial access
200 – 250 BFR
Absence
of
infiltration
Week 3
15g venous and arterial cannulations
250 – 300ml/min BFR
Absence
of
infiltration
Arrange removal of CVC
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Appendix 2
Adopted from the World Health Organization and Hand Hygiene Australia.
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