1) The document provides guidelines for caring for and maintaining an arteriovenous (AV) vascular access, including an AV fistula or graft. It discusses assessing the access before cannulation, identifying appropriate cannulation sites, performing cannulation safely, and removing needles properly.
2) It also outlines a staged protocol for cannulating a new AV access, starting with single cannulation by experienced nurses and progressing to double cannulation and larger needle sizes over time.
3) Maintaining the access involves daily exercise, avoiding heavy lifting or tight clothing on the arm with the access, and properly cleaning and caring for it before and after each treatment.
3. Keep Your AV Access Healthy
1. Feel the thrill every day
2. Do not carry heavy objects with the fistula arm
3. Do not wear watch or other accessories, on this arm
4. Do not use too tight clothes
5. Do not allow drawing blood and IV drip in the arm of the fistula
4. Keep Your AV Access Healthy
6. Do not allow evaluation of the arterial tension in the arm of the
fistula
7. Exercise the arm in order to develop fistula
8. Maintain good personal hygiene (bathing)
9. Wash the arm of the fistula before starting EVERY treatment
10.Do not shave the arm of the fistula
11. Do not scratch the skin, or remove crusts from any wound in the
arm of the fistula
6. Arm Fistula
Press and release with fast moves, a soft ball
10 minutes, 6 times per day
Press repeatedly a clothes-hanging clip
5 minutes, 6 times per day
Touch the tip of the thumb with every finger of
your hand, opening your hand after every
touch
5 minutes, 6 times a day.
7. Upper Arm Fistula
Use a weight, ≤1.5kg and with slow
movements go up and down, with
your arm
10 minutes, 6 times per day.
9. Assessment Before EVERY Cannulation
Observation:
Alterations in the access: Compare to the other arm or leg
(skin color, circulation, integrity)
Signs and symptoms of steal syndrome
Size of the cannulation vein, areas of cannulation, signs of infection,
presence of aneurisms
10. Assessment Before EVERY
Cannulation
Palpation:
Alterations on temperature of the arm or leg
Presence of thrill and pulse
Auscultation:
Presence of bruit throughout the access
11. Identify Cannulation Sites: AVF
The arterialized vein, the segment
must be as straight as possible
Segment should have at minimal the
size of the needle
Arterial cannulation ≥ 3.5cm from
the arterial anastomosis
Distance between needles ≥ 2.5cm
(6cm between the tip of the needles)
12. Identify Cannulation Sites: AVF
Arterial cannulation maybe in any direction, but when
possible antegrade direction is recommended.
Venous cannulation always towards the blood flow of
the access
Avoid aneurisms and doubtful trajectories.
13. Identify Cannulation Sites: Straight AVG
Divide the graft’ in half’;
Start cannulating at middle
and move out
Subsequent needle sites 0.5
to 1 cm apart
When 2.5 cm from
anastomosis return to start
14. Identify Cannulation Sites: Looped AVG
Divide at mid point
Don’t cannulate in the loop area, only
the straight segments
Dedicate one segment to arterial sites
and the other to venous sites
Move needle sites 0.5-1 cm apart
When 2.5 cm close to the anastomosis
return to the start of the segment
17. Choose the Right Needle Size
Needle Gauge BFR (mL/min)
17 <250
16 <300
15 <450
14 ≥450
AP >-250 mmHg VP <200 mmHg
18. Prepare for
Cannulation
Ensure appropriate hand hygiene and
PPE
Wash arm:
Transient flora is a source of infection
Ensure that skin is properly dried
Ensure appropriate supplies are at hand
19. Skin Preparation
Clean with antibacterial agent:
−70% alcohol
−2% chlorhexidine in 70% alcohol
Do not go over the already cleaned area with the same cleaning wipe
Allow adequate contact time: 15 seconds
−Allow area to dry
20. Cannulate the Access
Stabilize the patient’s hand
Hold and slightly secure the skin
Chose the appropriate angle of cannulation:
20-35° in fistulas
45° in grafts
Cannulate, preferably, with the bevel up
21. Cannulate the Access
Verify if there is blood flow to the needle, as soon as
the vessel is penetrated
Always aspirate blood first
Progress the needle in the same angle of
cannulation
Verify if blood flow is adequate
If necessary, as a last resource, rotate the needle
Release the tourniquet if used
22. Safe Taping – Prevent VND
Place 1st tape strip over the needle insertion site and wings
Chevron
Place 2nd tape strip
Place 3rd tape strip around needle tubing and secure it
24. Needle Removal
Wear PPE
Do not apply pressure as needle is withdrawn
Press immediately upon needle removal
Remove needle using the same angle performed during cannulation
25. Compression
Two fingers to compress
Pressure applied at 90 degree angle to
the skin
Try to avoid clamps as the pressure is
static
Involve patient
Vary pressure to maintain equal
pulse/thrill and control bleeding
26. Post Needle Removal Care
Apply dressing post treatment
Adequate to cover site and protect
Avoid excessive pressure that may restrict
blood flow
30. First Cannulation
STAGE I SINGLE CANNULATION
1st Arterial cannulation (preferable upwards, downwards if necessary):
Cannulated only by the most experience or accurate nurse in
cannulation.
Use of 17G needles recommended.
2nd – 3rd Arterial cannulation:
Cannulated only by the most experience/accurate nurse in cannulation;
use17G needle
31. Double Cannulation
STAGE II DOUBLE CANNULATION
1st Double cannulation (preferable upwards; venous always
upwards:
Cannulated only by the most experience or accurate nurse in
cannulation; G17
2nd – 3rd Double cannulation
CVC can be possibly removed after 2 weeks of double cannulation
without complications
32. Double Cannulation With
CVC Removed
STAGE III DOUBLE CANNULATION WITH CVC REMOVED
Double cannulation
Cannulated recommended by the most experience or accurate
nurse in cannulation.
Use of 16G needles recommended until the 8th week or upon
assessment of experience nurse.
33. Double Cannulation With CVC Removed
STAGE IV DOUBLE CANNULATION WITH CVC REMOVED
Double cannulation
Cannulation endorsed by the most experience or accurate nurse in
cannulation to the Charge Nurses/ Senior Nurses/Junior Nurses.
Increase to 15G or 14G upon assessment of experience nurse.