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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

• Hands:
• Redness
• Drainage Infection
Painful Steal
• Abscess
Numb Syndrome
• Fingers:
• Skin color Central Discolored
• Edema or
• Small blue outflow • Prior cannulation sites
or purple vein • Collateral/accessory
veins stenosis veins
9 Warmth = possible infection
9 Cold = decreased blood supply

9 Normally only present at the
9 A thrill can be felt at a major stenosis.

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


9 Listen every treatment

9 Changes in characteristics:
9 Determine direction of flow
Causes of Stenosis

• Turbulence

• Aneurysm and pseudoaneurysm


• 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
Central Vein Stenosis
Physical Findings of Venous Stenosis


Thrill Only at the arterial At site of

anastamosis stenotic lesion

Pulse Soft, easily Water-hammer

Bruit Low pitch High pitch
Continuous Discontinuous
Diastolic & systolic 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
• Neurologic damage to the hand can
• 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 increases their risk for
The Allen Test (negative)


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
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
Says Who?
K/DOQI SAYS 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
•Guideline 14: Skin and/or 10% povidone iodine using a circular
rubbing motion.
Preparation Technique for Notes:
ƒ Alcohol has a short bacteriostatic action
Permanent AV Accesses time and should be applied in a rubbing
motion for 1 minute immediately prior to
needle cannulation.
• A clean technique for ƒ Povidone iodine needs to be applied for 2-3
minutes for its full bacteriostatic action to
needle cannulation should take effect and must be allowed to dry prior
to needle cannulation.
be used for all cannulation ƒ Clean gloves should be worn by the dialysis
staff for cannulation. Gloves should be
procedures (Evidence). 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
• Ethyl chloride – spray arterial site, prep skin,
then insert needle immediately. Repeat for
venous site.
• Topical anesthetic creams (EMLATM and less-
n-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
• Pull the skin taut to allow easier needle insertion.
• Compresses the nerve
endings, blocking pain
sensation to the brain
for approximately 20
Angles of Entry

Rule of Thumb: Reality:

20-35o angles for Not every access fits

fistulae the Rule of Thumb.

You will need to

• 45o for grafts carefully assess the
depth of the access and
adjust the angle of
cannulation accordingly.


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.

• Caused by
sticking needles
in the same
general area.

• Cause stenosis
because of
Photo courtesy of P. Cade

• “One-site-itis”
occurs when you Vascular Access

stick the needle in

the same general Area puncture technique

area, day after day. aka “one-site-itis”

• Causes aneurysm
and stenosis
Thrombosis in AV Fistula

• Early cause:
*technical issues
• Late causes:
* poor blood flow
*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
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


• Use two fingers per

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.


Buttonhole –

The old
Facts About Buttonhole

• Used in Europe for over 25 years.

• First used on a patient with a limited area for


• 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 Vascular Access

every time. Constant site technique

aka Buttonhole technique

• This technique has

not been shown to
cause aneurysm
Buttonhole Considerations
• Requires the same cannulator until the
track is formed (~ 8 sticks, ~12 for
• 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

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


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?
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

• Successful = getting two needles in,

no infiltrations, and reaching the
prescribed blood flow rate for six
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



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’

• As a cannulator of vascular access for

hemodialysis patients, strive to be the
best you can be.