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Vascular Access for hemodialysis
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1
VASCULAR ACCESS IN HEMODIALYSIS
Dr. IRFAN ELAHI
Consultant Nephrologist
Mayo Hospital Lahore
BY
3
Native Arteriovenous fistula (AVF)
Prosthetic arterio-venous graft (AVG)
Cathater
Temporary double lumen cathater
Permanent Cathater
THERE ARE 3 TYPES OF VASCULAR ACCESS
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A V GRAFTS
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Benefits of Arteriovenous Fistula (AVF)
Lowest rate of failures and complications
Longevity
Lowest costs
BENEFITS OF ARTERIOVENOUS FISTULA (AVF)
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Definition
Process by which a fistula becomes suitable
for cannulation (ie, develops adequate flow,
wall thickness, and diameter).
FISTULA MATURATION
Rule of 6’sIn general, a mature fistula should:
Be a minimum of 6 mm 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
Be evaluated for non maturation 4–6 weeks after surgical creation
FISTULA MATURATION
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The fistula should be examined regularly following
surgery. At 4 weeks post surgery, the fistula should be
evaluated specifically for non maturation.
CLINICAL CLARIFICATION
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Look, listen, and feel the new AVF at every dialysis treatment
After the scar heals, begin assessing AVF using a “gentle”
tourniquet placed high in the axilla area
Instruct patient to start access exercises after healing
Document patient education as well as condition and
maturation of the AVF
DURING AVF MATURATION PROCESS
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Vessel diameter must be 4–6 mm
Vessel walls should toughen and be firm to the touch
There should be no prominent collateral veins
MATURING FISTULA
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TOURNIQUET
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IS NEW AVF MATURE AND READY FOR CANNULATION?
AVF
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Vein looks large enough
Vein feels prominent and straight
Vein has a strong thrill and good bruit
IS AVF MATURE AND READY FOR INITIAL CANNULATION?
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What diagnostic tools or techniques can be used
to determine if an AVF is ready for cannulation?
Can the same tools or techniques be used to
select the cannulation sites?
FISTULA MATURATION
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Duplex Doppler study Physical exam by the: Nephrologist Nephrology nurse Surgeon Angiogram (fistulogram)
DIAGNOSTIC TOOLS/TECHNIQUES TO DETERMINE IF AN AVF IS READY
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Physical ExamLook, Listen, and Feel Using;
Eyes
Ears
Fingertips
BEST TOOL/TECHNIQUE?
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Physical Exam
Firm, no longer mushy
Vessel wall thickening
Vessel diameter enlargement (to 4–6 mm)
Absence of prominent collateral vein
If in doubt, “Just Say No”
MATURING FISTULA
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Look for Changes compared to opposite extremity Skin color/circulation Skin integrity Edema Drainage Vessel size/cannulation areas Aneurysm Hematoma Bruising
INSPECTION
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Temperature Change
Warmth = possible infection
Cold = decreased blood supply
PALPATION
Thrill
PALPATION
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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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Feel for Size, Depth, Diameter, and Straightness of AVF
Feel the entire AVF from arterial anastomosis all the way
up the vein
Evaluate for possible cannulation sites = superficial,
straight vein section with adequate and consistent vein
diameter
PALPATION
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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
AUSCULTATION
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Communicate assessment findings with access team,
including surgeon
Check maturity progress every session
Assure evaluation by surgeon 4 weeks post-op
Intervene if there is no progress at 4 weeks or AVF is not
mature and ready for cannulation at 6–8 weeks
POST-OP FOLLOW-UP
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Must have:
Physician’s order to cannulate
Experienced, qualified staff person who is successful with new
fistula cannulations
Use of a tourniquet or some form of vessel-engorgement
technique (e.g, staff or patient compressing the vein)
BASIC REQUIREMENTS FOR CANNULATION
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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)
NEEDLE GAUGE
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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
Back-eye opening allows blood intake from both
sides of the needle; can be used as arterial or
venous needle
Non–back-eye needle—for
venous use only
Arterial needle Venous needle
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BACK-EYE NEEDLE FLOW
Allows blood toenter or exit from
both the bevel and back-eye
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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
NEEDLE DIRECTION
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Venous needle
directed back
toward the heart
Arterial needle
directed toward the
arterial anastomosi
s (retrograde)
Needle Direction
36
Venous needle
directed back
toward the heart
Arterial needle also
directedback toward
the heart (antegrade)
Needle Direction
37
Always use a tourniquet, regardless of the size or
appearance of vessel
Use of the tourniquet helps to engorge, visualize, palpate,
and stabilize the AVF
Use 20–35° angle for needle insertion for an AVF
NEW AVF CANNULATION PROTOCOL
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“WET” NEEDLE
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On removal of needles, for hemostasis:
Use 2-finger compression
Never use clamps
Hold sites for 10 minutes—no peeking
NEW AVF CANNULATION: ADDITIONAL POINTS
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Check fistula daily for a thrill and bruit
Check for signs and symptoms of infection or other
complications
Write instructions for fistula care
EDUCATION FOR PATIENTS
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Thrill is undetectable
Patient becomes feverish, dehydrated, or
experiences low blood pressure
CALL THE NEPHROLOGIST/PHYSICIAN
CANNULATION SITE SELECTION AND PREPARATION
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Assess AVF before every cannulation Compare arms for changes in skin color, circulation, integrity Inspect
Access extremity for central or outflow vein stenosis Distal areas of extremity for steal syndrome Access for vessel size, cannulation areas, infection, aneurysms
PHYSICAL ASSESSMENT
PHYSICAL ASSESSMENT
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Palpate
Temperature change may mean infection or stenosis
Change in thrill may mean stenosis
Auscultate
Listen to entire access for changes in bruit that indicate
stenosis
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Look and feel for a straight segment of AVF Segment must be as long as the needle length (ie, 1″ minimum) Stay at least 1.5″ from the AVF anastomosis The arterial and venous needles need to be 1″ to 1.5″ apart Avoid curves, flat spots, and aneurysms to prevent complications
IDENTIFY IDEAL SEGMENT OF AVF
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Dialysis patients have more 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
SITE PREPARATION
If possible, patient should
wash the access with
antibacterial soap before
coming to the chair
Staph is the leading cause
of infection in dialysis
patients
SKIN PREPARATION
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Proper needle-site preparation by both the patient and staff reduces infection rates Once the skin site is properly cleansed, the skin should not be touched with bare hands or gloved hands
If touched, re-prep the skin All site selection should be done prior to the final skin preparation
SKIN PREPARATION
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Wet insertion site for 30 sec Allow to air-dry for ≈30 sec Do not blot or wipe
APPLYING CHLORHEXIDINE GLUCONATE
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Saturate sterile gauze pad Clean sites with circular motionWait 2 minutes before proceeding
APPLYING SODIUM HYPOCHLORITE
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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 Do not touch skin after cleansing area
PROPER CLEANSING TECHNIQUE
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KDOQI Says
For all vascular accesses,aseptic
technique should be used for all
cannulation and catheter
incertion procedures (evidence)
SAYS WHO? 1. Locate, inspect and palpate the
needle cannulation sites prior to skin preparation. Repeat prep if the skin is touched by the patient or staff once the prep has been applied, but the cannulation not completed.
2. Wash access site using an antibacterial soap or scrub and water.
3. Cleanse the skin by applying 2% chlorhexidine gluconate/70% isopropyl alcohol and/or 10% povidone iodine as per manufacturer’s instructions for use.
Notes: 2% chlorhexidine gluconate/70%
isopropyl alcohol antiseptic has a rapid (30 s) and persistent (up to 48 hr) antimicrobial activity on the skin. Apply solution using back and forth friction scrub for 30 seconds. Allow area to dry. Do not blot the solution.
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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
ANESTHETIC OPTIONS FOR PAIN CONTROL
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Lidocaine injected under the skin and above the vessel Advantage: Numbs the area prior to the cannulation procedure Disadvantages: Can cause scarring, vasoconstriction, keloid formation,burning with injection, and poses a needle-stick risk
INTRADERMAL ANESTHETICS
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Topical sprays (ethyl chloride) can be used to numb the skin sites Advantage: Noninvasive method of numbing the skin Disadvantages: Nonsterile, requires patient-specific bottle to prevent cross-contamination, may discolor or damage skin with long-term use, flammable contents in bottle Method: Spray arterial site, prep skin, then insert needle immediately; repeat for venous site
TOPICAL SPRAYS
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Wash skin first Apply 1 hour before dialysis Cover with plastic wrap Prior to cannulation, remove cream, wash/prep skin
USING TOPICAL CREAMS
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Tourniquet required for all cannulations Apply tightly enough to engorge vessel
TOURNIQUET USE
CANNULATION TECHNIQUES
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Site-RotationAlso known as:
Rope ladderRotating sites
CANNULATION TECHNIQUES
ButtonholeAlso known as:
Constant-siteSame-site
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Take your timeCannulation is achieved in a gentle mannerDetermine the depth of the access during your assessment—this will determine the angle of entry into the fistula
IMPORTANT TIPS
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Cannulation sites are rotated up and down the AVF to use its entire length Classic technique used in most dialysis centers
SITE-ROTATION TECHNIQUE
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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″ away from the anastomosis Keep the needles at least 1.5″ apart Each treatment requires 2 new sites
LOCATING THE CANNULATION SITE
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Proper site-rotation cannulation technique with
rotation of both venous and arterial needle sites
Venous site-rotation cannulation
sites
Arterial site-rotation cannulation
sites
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Improper site-rotationcannulation technique with
rotation of both venous and arterial needle sites
Poor venous site rotation
Poor arterial site rotation
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“One-site–itis” occurs when
you stick the needle in the
same general area, session
after session
Causes aneurysm and stenosis
formation
“ONE-SITE–ITIS”
Practice of repeatedly puncturing same area,
AKA“one-site–itis”
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Caused by sticking needles in the same general areaAneurysm can also result from stenosis beyond the aneurysm, causing elevated back pressure
AVF ANEURYSM
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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 needleThe venous needle can be back-eye or non–back-eye
NEEDLE INSERTION
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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)
THREE-POINT TECHNIQUE
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“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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Rule of Thumb
20–35° angles for fistulae
45° for grafts
ANGLES OF ENTRY
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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Secure wings Sterile gauze or adhesive bandage over insertion site
Chevron to prevent dislodging Additional tape as needed
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Prep skin prior to cannulation
Stabilize the skin and the AVF
PREPARING FOR CANNULATION
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Use an approximately 20–35° angle of insertion depending on the depth of the access The angle is from the skin to the needle hub First, enter the skin and tissue above the AVF vessel, then the vessel
INSERTION OF NEEDLE
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Once the AVF vessel is entered, the blood flashback is visible in the needle tubingLevel out and advance the needle with very minimal pressure
ADVANCING THE NEEDLE
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Do not “flip” or rotate the bevel of the needle 180°
Flipping can lead to stretching of theneedle-insertion site and cause oozing during the dialysis treatment
PLACEMENT IS CRUCIAL
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Apply gauze dressing without pressureRemove needle at insertion angleApply pressure with 2 fingersDo not use excessive pressure Hold for 10–12 minutes, no peekingUse stethoscope to check for bruit after applying dressing to stick site
NEEDLE REMOVAL
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USE A STETHOSCOPE TO CHECK FOR BRUIT
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Apply adhesive bandages Dispose of needles in biohazard sharps container per guidelines specified in the Occupational Safety and Health Act (OSHA)
NEEDLE REMOVAL
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Pull needle completely from the vein before pushing down on the needle siteHold direct pressure for 10 minutes without “peeking”—no exceptions Do not use clamps unless absolutely necessary!
POST-TREATMENT HEMOSTASIS
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Method in which an individual cannulates the AV fistula in the exact same spot, at the same angle and depth of penetration every time A scar tissue tunnel track develops, allowing for the use of a buttonhole (blunt) fistula needle
BUTTONHOLE TECHNIQUE
Procedure
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May prolong AVF lifespanReduces pain, bleeding, infiltration, infectionVirtually eliminates missed cannulationsPromotes self-care and self-dialysisUse blunt needles, which require no safety device
ADVANTAGES
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Requires same cannulator, same angle, same location Concerns of “one-siteitis”Difficult with fistula covered by:
Heavily scarred skin Large amount of subcutaneous tissue
DISADVANTAGES
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AVF BUTTONHOLE TECHNIQUE
Buttonhole sites
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TWO BUTTONHOLE SITES
Buttonhole sites
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Change blunt needles once the track
is formed
Blunt needles prevent continued cutting of
the buttonhole track and new entry site of the AVF vessel
Blunt needles prevent infiltrations, bleeding from around the
needle sites, and resistance to the needle insertion into the
track and vessel
CHANGING TO BLUNT NEEDLES
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NEEDLES—SHARP AND BLUNT
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A ridge is starting to developA hole is starting to developThis site is not yet ready for a blunt needle
A DEVELOPING BUTTONHOLE
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Needle inserted into the buttonhole tunnel track,but the angle is not aligned with the vessel flap The needle can bounce on the vein and not displace the vessel flap
BUTTONHOLE: WRONG ANGLE OF INSERTION
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Adjust angle to find the flapLift up and down on the needle to readjust the angle until the needle drops into the vessel flap
BUTTONHOLE: ADJUSTED ANGLE OF INSERTION
Causes
BUTTONHOLE: ADJUSTED ANGLE OF INSERTION
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Moving needle from angle used to enter the skin, arm
positioning not in routine place, or patient weight gain
or loss
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It may be possible to speed the development of buttonhole sites by cannulating the sites every dayIt is helpful to switch over to blunt needles as soon as possible
Long-term use of sharp needles will cut adjacent tissues, enlarge the hole, and cause bleeding along the needle path
HELPFUL HINTS…
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If it is impossible to have only 1 cannulator, additional buttonhole sites can be developed at the same time using a second cannulatorIf your patient is hospitalized and the acute hospital renal team does not know how to access a buttonhole, they can:
Rotate sites using standard sharp needles as long as they stay ¾″ away from the buttonhole tracks
ORHave the patient self-cannulate (if the patient has been trained)
MORE HELPFUL HINTS…
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Plan outreach to the acute team and educate regarding buttonhole technique
Continue access monitoring and surveillance, even if patient is dialyzing at home
Inform patients that laminated procedure cards and videos are available
STILL MORE HELPFUL HINTS…
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Bleeding can occur around the needles during dialysis if: You are using sharp needles and have cut the trackThe track has stretched because of trying to direct the needle instead of following the trackYou have made a new track and torn tissue
TROUBLESHOOTING THE BUTTONHOLE
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If, after the weekend, you have trouble with blunt needles, switch to sharp needles for that day, being careful not to cut the track
If a site is not progressing, it is acceptable to abandon that site and find another site
TROUBLESHOOTING THE BUTTONHOLE
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Difficulty re-entering the fistula veinCan occur when transitioning from sharp to blunt needles
The blunt needle “bounces” on the vessel and will not enter the vessel
Corrective action: Change the needle angle slightly until the vessel flap is located and needle drops into the vessel
If it persists, return to sharp needle for a few sessions and then try blunt needle again
TROUBLESHOOTING THE BUTTONHOLE
COMPLICATIONS
95
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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
BLEEDING
BLEEDING
99
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
100
INFILTRATION = HEMATOMA
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Don’t flip needleDon’t lift needle in veinFlush with NSS
PREVENT CANNULATION INFILTRATIONS
102
Apply gauze without pressureRemove needle at insertion angleApply pressure with 2 fingersHold pressure 10–12 minutes
PREVENT POSTDIALYSIS INFILTRATIONS
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Elevate arm above heartIce 20 minutes on/20 minutes off for 24 hoursWarm compresses after 24 hoursLet fistula restSecond infiltration: Notify vascular access teamDon’t use AVF until directed
TREATING INFILTRATIONS
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If the fistula infiltrates, let it “rest” until the swelling is resolved ( KDOQI Guidelines)If the fistula infiltrates a second time, the RN should notify the vascular access team, including the surgeon, as soon as possible for interventionDon’t use that AVF until further directed
INFILTRATIONS IN NEW AVF
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Check for flashback and aspirateFlush with NSS to ensure the needle flushes with ease and there are no signs or symptoms of infiltrationSaline causes much less damage and discomfort than blood if an infiltration occurs
HOW TO PREVENT INFILTRATIONS
106
If bruising or hematoma occurs after dialysis, the surface skin site has sealed but the needle hole in the vessel wall has notUse 2 fingers per site for hemostasisIt is crucial to apply pressure to both the skin and access wall puncture sites
POST-CANNULATION BRUISING AND HEMATOMA
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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 optionsUse tourniquet for cannulation only!
Do not leave in place for entire treatment!!!
POOR FLOW
108
Caused by stenosis as vessel narrowing increases “back pressure,” causing vessel distension and weakening of vessel wallMay also be causedor aggravated by frequent cannulations in the same area
ANEURYSM
109
Most common complicationCauses:
IV, CVC, linesSurgery to create AVFAneurysms
May be caused by the back pressure associated with stenosis
Needle-stick injury
STENOSIS
110
Frequent cause of early fistula failure Juxta-anastomotic stenosis most
common
STENOSIS
Stenosis
111
Juxta-anastomotic (most
common stenosis in AVF)
Mid-access
Outflow
Central vessel
TYPES OF STENOSES
Outflow
Central-vein
Mid-access
InflowForearm AVF
112
CENTRAL-VEIN STENOSIS
113
DISTENDED, OBSTRUCTED LEFT SHOULDER VEINS INDICATIVE OF
CENTRAL-VEIN STENOSIS
114
Clotting of the extracorporeal circuit 2 or more times/monthPersistently swollen access extremityChanges in bruit or thrill (ie, becomes pulse-like)Difficult needle placementBlood squirts out during cannulationElevated venous pressures
CLUES TO STENOSIS
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Excessively negative pre-pump APDecreased blood pump speedsInability to achieve BFRChanges in Kt/V and URR RecirculationProlonged postdialysis bleeding Frequent episodes of access thrombosis
CLUES TO STENOSIS
116
Surgical/technical problemsPreexisting anatomic lesions (eg, old IV injury)Premature usePoor blood flowHypotensionHypercoagulationFistula compression
THROMBOSIS
117
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 temperatureSwelling, hardnessDrainage from incision, needle sitesTenderness or pain
INFECTION
INFECTION
118
Patient complaints without other indications of Malaise Fever
119
PreventionGeneral hygiene
Pretreatment washing of access extremityHand washing, before and after cannulationNo scratching, irritation of skin of access extremity
Precannulation Appropriate skin antisepsisSufficient antiseptic-skin contact time Cannulate while antiseptic is wet or dry, as directed
Cannulation Maintain needle sterilityDo not cannulate through scabs or abraded areas
PREVENTION OF INFECTION
120
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
STEAL SYNDROME/ISCHEMIA
STEAL SYNDROME/ISCHEMIA
121
Neurological and soft tissue damage to the hand can occur,
resulting in mobility limitations (eg, grip strength, dexterity),
loss of function, ulcerations, necrosis
Steal syndrome/ischemia is estimated to occur in
approximately 5% of vascular access patients, mostly those
with diabetes and peripheral vascular disease (PVD)
122
“CLAW HAND” CONTRACTURE FROM STEAL SYNDROME
123
Steal symptoms may improve due to the development of collateral circulationProcedures, such as the DRIL (distal revascularization-interval ligation), can successfully treat steal and ischemiaIndividuals who are at high risk for developing acute steal are:
Patients with diabetic neuropathyPatients with PVD
STEAL SYNDROME/ISCHEMIA
124