On Course With Cannulation

On Course With Cannulation Lynda K. Ball, RN, BSN, CNN Quality Improvement Coordinator Northwest Renal Network

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

Inspection • Redness • Drainage • Abscess • Skin color • Edema • Small blue or purple veins

Infection

• Hands: Cold Painful Steal Numb Syndrome • Fingers: Discolored

Central or outflow • Prior cannulation sites • Collateral/accessory vein veins stenosis

Palpation Temperature 9 Warmth = possible infection 9 Cold = decreased blood supply Thrill 9 Normally only present at the anastamosis. 9 A thrill can be felt at a major 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

Auscultation Bruit 9 Listen every treatment 9 Changes in characteristics: discontinuous high-pitched louder-pitched 9 Determine direction of flow

Causes of Stenosis • Turbulence • Aneurysm and pseudoaneurysm formation • Needle stick injury to vessel wall

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.

Central Vein Stenosis

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

Clinical 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 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? • 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 (negative)

Preparation for Cannulation

Skin 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 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.

A 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 lessn-painTM) must be applied to the access, then wrapped with saran wrap one hour prior to dialysis. Patient washes off at dialysis.

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.

Angles 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.

Problems associated with dialysis

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. • Larger bore needles can reduce pressure, if available.

Aneurysm • Caused by sticking needles in the same general area. • Cause stenosis formation because of turbulence Photo courtesy of P. Cade

“One-site-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 Fistula • Early cause: *surgical *technical issues • Late causes: * poor blood flow *hypotension *hypercoagulability *patient compressing while sleeping

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.

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

Buttonhole – The old becomes new again!

Facts 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 “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

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 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 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 Log Date

S/B

Ga

QB

Art Pres

URR

Comments and/or complications

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 #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., dire of 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 Buttonhole

Developed Buttonhole Sites

Photo courtesy of V. Muchow

Photo courtesy of J. Weintraub

Cannulating a New AV Fistula

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 ¾ Pre-pump AP tells us blood pump force can if the AVF has good cause massive flow. hematoma ¾ Lower risk of ¾ No use until complications hematoma resolves

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.

Facts 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

Conversion of Grafts to AV Fistulae

“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… • 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.