Vascular Access Revised
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Transcript of Vascular Access Revised
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7/27/2019 Vascular Access Revised
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TECHNIQUE ON CANNULATIONOF
FISTULA AND GRAFTS
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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
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Access Physical Examination
ExamSteps
Fistula(Normal)
AVG(Normal)
Stenosis orPoor
Maturation(Abnormal)
Infection or StealSyndrome(Abnormal
LISTEN Low pitchcontinuousdiastolic &systolic
Low pitchcontinuousdiastolic &systolic
High pitchdiscontinuoussystolic only
STEALSYNDROME:
Fistula may havea very strongbruit
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Access Physical ExaminationExamSteps
Fistula(Normal)
AVG(Normal)
Stenosis orPoor
Maturation(Abnormal)
Infection or StealSyndrome(Abnormal
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)
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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.
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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.
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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.
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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.
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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.
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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.
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Cannulation
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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
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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.
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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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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.
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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.
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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.
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BFR for Specific Needle
Gauges
Gauge 17 BFR : 200-250ml/min
Gauge 16 BFR : 250-350ml/min
Gauge 15 BFR : 350-450ml/min
Gauge 14 BFR : >450ml/min
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THANK YOU