Download - 5H9-Fistula Cann Training
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1Vascular Access Evaluation and
Cannulation Training
Cheryl George RN, QI Nurse, ESRD Network 13 [email protected] 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
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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)
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2Disclaimer
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
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3AV FistulaWHY 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
o Loop/straight grafts: 3-4 weeks healing time
o Always rotate cannulation sites to prevent pseudo-aneurysms
o Cannulate at 45 angle
o Confirm entry via blood flash-back
o Trend venous pressures for stenosis monitoring
o NewHeRO Vascular Access Device
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4Fistula
Artery Vein
Graft
Artery Vein
Artery and vein
are
connected creating
an
opening between the two Artery and vein are connected
by a tube between the two vessels
o What is the HeRO device?
o 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).
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5SLEEVES 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 capsFollow facility protocol!
Monitor closely Highest Risk of infectionS/S infection at exit site: Sepsis:Redness, Swelling, Drainage Undocumented hypotension
Fever
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6Why is today important?
Improper cannulation
technique and skill level may
lead to:
premature access failure
patient fear or reluctance
Staff turnove
r
Assessment
Cannulation technique
Cannulation skill level
Infection
Fistula Development
Adequate Blood Flow
Needle Placement
A-V Direction
How can we prevent premature AVF access failure?o Good techniqueo Assessment of A-V Fistula
prior to cannulationo Skill level of cannulator
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
Fistula Maturation
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7NKF-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/DOQIPreferred
Assessment Best Tool/Technique?
Look Listen Feel
Do you perform a physical exam of your patients accessbefore each treatment?
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8L K: Compare extremities
Color change
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
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9Feel: 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
StenosisA narrowing of the vessel
Normal Narrowing Clotted
Thrill/Bruit Pulsatile
Collapsed - With Elevation Dilated
Pressure
Strong pulsation felt during palpation of the fistula during the assessment indicates stenosis
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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 post-dialysis
Elevated venous pressure
(frequent alarms)
Excessive negative prepump 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 (CPG 5.6.1)KDOQI Guidelines 2006
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 Guidelines1. 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.
Skin-PreparationTechnique for
PermanentAV Accesses
A clean technique for
needle cannulation
should be used for all
cannulation procedures(evidence)
Proper needle-site preparation reduces infection rates
If touched, re-prep the skin
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
Once the skin site is properly cleansed, the skin should not be touched with bare hands or gloved hands
Needle site
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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
FeelingPalpate accessGently compress access midpointArterial inflow will pulse with flowVenous outflow will have diminished or no pulse
ListeningAuscultate accessGently compress access midpointArterial inflow will have pulsatile soundVenous 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 theaneurysm, 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 RuptureA 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 15-gauge 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 acceptthe 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 AnxietyCannulation 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 nonback-eye
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 Fistula2035 angle of insertion depending on the depth of the access
Fistula needle/wings are the extension of your hands and fingersCareful not to touch needle withgloves/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
The angle is from the skin to the needle hub
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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Three-Point
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 anyIntervention
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 TrendingAdverse 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 AccessNational 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 2008-2009\ Fistula Cannulation Training