vascular access revised

7/27/2019 Vascular Access Revised

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2/23

TECHNIQUE ON CANNULATIONOF

FISTULA AND GRAFTS


3/23

Access Physical Examination

ExamSteps

Fistula (Normal) AVG(Normal)

Stenosis orPoor

Maturation(Abnormal)

Infection or StealSyndrome(Abnormal

LOOK >Welldevelopedvein outflow>No dilatedareas oraneurysm

formation>Areas ofstraight vein>Vessel partiallycollapses whenarm is elevated

>Uniformsized graft

>Noirregularareas or

aneurysms

>Fistula withmultiplevenousoutflow veins> Look for anarrowing of

the outflowvein oraneurysms.> Dilated neckveins or smallsurface

collateral veins

INFECTION> Redness,Swelling, BrokenSkin, Drainage,Induration.

STEALSYNDROME>Discoloration ofthe access hand>Check for nailbeds and hands


4/23

Access Physical Examination

ExamSteps

Fistula(Normal)

AVG(Normal)

Stenosis orPoor



LISTEN Low pitchcontinuousdiastolic &systolic

Low pitchcontinuousdiastolic &systolic

High pitchdiscontinuoussystolic only

STEALSYNDROME:

Fistula may havea very strongbruit


5/23

Access Physical ExaminationExamSteps

Fistula(Normal)

AVG(Normal)

Stenosis orPoor



FEEL Thrill at the

arterialanastomosisand theentire outflowvein

Thrill

strongest atthe arterialanastomosisbut must befelt at theentire graft

Fistula & Graft:

Pulse at thesite of thestenotic lesion.Pulse has awater hammerfeel

Graft: Feelsmushy orirregular inshape. Can bea site of

aneurysm

INFECTION:

> Warm totouch, Swelling

STEALSYNDROME:> Feel bilateral

limbs andcompare them(temperature,grip strength,ROM andcomplaints of

pain)


6/23

Skin Preparation Techniques

1. Locate, inspect and palpate the needlecannulation sites prior to skin prep.

2. Wash access with antibacterial soap andwater

3. Cleanse the skin by applying 2%chlorhexidine gluconate/ 70% isopropylalcohol/ and or 10% povidone iodine.


7/23

Technique for Mature AVFCannulation

1. After skin prep

2. Apply tourniquet

3. Pull skin taut to the opposite direction ofneedle insertion

4. For easy palpated vessel, use a 25% angle ofinsertion bevel up

5. Once the vessel has been penetrated, lowerthe angle of the needle & advance theneedle slowly

6. Tape the needle at the same angle with theangle of insertion.


8/23

Technique for AV GraftCannulation1. After skin prep, pull skin taut in the opposite

direction of the needle insertion. Avoid excessivepressure to cannulation site.

2. Use 45 degrees angle of insertion.3. Once the vessel have been penetrated:

Advance the needle slowly with cutting edgefacing up

For a deep, hard to palpate AVG rotate theaccess of the needle to 180 degrees and

advance slowly.4. Tape the needle at the same angle as the

needle insertion.


9/23

Complications of vascularAccess

Venous Catheter (IJ, SC, Femoral) Most likely to develop infection and clotting

problems that may require medication and

catheter removal or replacement. AV Grafts May develop low blood flow which can be an

indication of clotting or narrowing of theaccess. May require surgery such asangioplasty.

AV Fistulas Infection and low blood flow are less common

but must still be monitored.


10/23

CANNULATION TIPS

A fistula that only works with a tourniquet in place isstill underdeveloped, usually because of inflowstenosis.

The combined use of the new fistula and bridgevascular access may be necessary until the fistula iswell developed.

Cannulation performed at a nonturnover time mayprovide more time for the cannulation procedure.

A needle with a back eye should always be usedfor the arterial needle.


11/23

Apply a tourniquet to the access arm.

After disinfecting the access site per unit protocol,carefully cannulate the fistula, using a 25 insertionangle.

When blood flash is observed, flatten the angle ofthe needle, parallel to the skin, and advance slowly.When the needle is in the vessel, remove thetourniquet and tape the needle securely per unitprotocol.

Assess for adequate blood flow by alternately

aspirating and flushing the needle with a syringe.

Assess carefully for signs of infiltration, ie, pain,swelling, or discoloration.

Repeat steps 1 to 5 for the second needle.


12/23

Cannulation


13/23

Infiltrations, Problems, and Tips

Infiltrations with the cannulation can occur before,during and after dialysis.

Monitor closely for signs and symptoms of infiltration.

The decision to leave the needle in place andcannulate another site may be appropriate.

Immediately applying ice can help decrease:o Paino Size of infiltrationo Bleeding time


14/23

Use caution when taping needles.

Avoid lifting up on the needle after it is in the vein.

If the fistula is infiltrated, it is best to rest the fistula forat least 1 treatment. If not possible, the nextcannulation should be above the site of theinfiltration.

If the patient still has a catheter in place, restart use

of the fistula with 1 needle and advance to 2needles, larger needle size, and greater BFRs as theaccess allows.


15/23

Proper needle removal prevents postdialysisinfiltrations.

o Apply the gauze dressing over the needle site, but

do not apply pressure.

o Carefully remove the needle at approximately the

same angle as it was inserted.

o Do not apply pressure to the puncture site until the

needle has been completely removed


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http://en.wikipedia.org/wiki/File:Radiocephalic_fistula.svg


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19/23

Patient Education Basics

All patients should be taught how to:

Compress a bleeding access

Proper washing of skin over the accesseveryday and before HD.

Recognize s/s of infection

Select proper methods of exercising fistula

Palpate thrill/pulse daily and after anyhypotension, dizziness, or lightheadedness.

Listen for bruit if palpation for thrill is not possible.


20/23

Patient Education Basics All patients should know how to:

Avoid carrying heavy items on the access arm

or wearing occlusive dressing. Avoid sleeping on access arm

Insist that staff rotate cannulation site eachtreatment

Ensure that staff uses proper techniques inhooking and wearing gloves and mask for allaccess connections

Reports signs and symptoms of infection orabsence of bruit/thrill to the dialysis personnel.


21/23

Health Teaching for Patients Regarding

their Vascular Access

Make sure your nurse or technician checks youraccess before each treatment.

Keep your access clean at all times.

Use your access site only for dialysis. Be careful not to bump or cut your access. Dont let anyone put a blood pressure cuff on your

access arm. Dont wear jewelry or tight clothes over your

access site. Dont sleep with your access arm under your head

or body. Dont lift heavy objects or put pressure on your

access arm. Check the pulse in your access every day.


22/23

BFR for Specific Needle

Gauges

Gauge 17 BFR : 200-250ml/min



Gauge 14 BFR : >450ml/min


23/23

THANK YOU

vascular access revised

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