Long-Term Complications of Fistula

Steal Syndrome
• Is a set of symptoms caused by hypoxia (lack of oxygen to the tissues).
• 'Patients feel pain that can range from minor to severe.
• In most patients, steal syndrome pain lessens over time because extra blood vessels grow and supply blood to the area (collateral circulation)
• Some of the symptoms to watch for or ask your patients about include:
• Pain in the access limb
• Tingling in the access limb
• Cold feeling in the access limb
• A change in motor skills in the hand.
• Nail beds that are blue in color
• Necrotic (dead / slacked) spots on the ...
• Decreased feeling in the access limb
• Try to keep the patient's hand warm during dialysis, perhaps with a mitten, blanket, or tube sock.
• Changing the position of the patient's arm may help increase blood flow in the hand
• Can be treated by reducing blood flow through the fistula, making the vessels larger, or tying off some blood vessels surgically.


Aneurysm
• Putting needles in the access in the same general area time after time can cause an aneurysm.
• This pattern of cannulation weakens the vessel wall and causes a bulge or "gumdrop" to"ballooning" to form the access.
• Aneurysms are more likely to occur upstream
(retrogradeO from a venous stenosis, especially at sites of repeat needle insertion.
The sites are easy to see.
• Rotate needle puncture sites or use the buttonhole technique to prevent aneurysms.
• Do not insert needles into areas of aneurysms.
• Aneurysms leave less surface area for cannulation.


Stenosis
• Is a narrowing of the blood vessel that shows the flow of blood through the access.
• There are three major sites where stenosis is likely to form:

1. Inflow
• The most common type of inflow stenosis is called juxta-anastomotic stenosis (JAS).
• It is found in the vein right next to the anastomosis.
• It will keep a fistula from maturing because it does not allow enough blood flow to enter the fistula.
• It may be due to stretching, twisting, or other trauma during the fistula surgery.

2. Outflow
• Can occur anywhere along the outflow vein.
• May occur in an area where the patient has had an IV placed in the past.
• The area past the stenosis may appear smaller, making needle insertion more difficult for fear of infiltration.

3. Central vein
• Central venous stenosis occurs in the large draining vein of the arm, often in the shoulder area.
• If a stenosis is suspected, the venous system should be checked from the fistula to the heart, so a central stenosis can be found.
•These stenosis are most likely caused by catheter placement in the past.

Stenosis Symptoms:

• High-pitched or louder-pitched bruit
• Harsh or water-hammer pulse
• Discontinuous bruit (each sound separate - whoosh . whoosh... whoosh) Decreased thrill
• Trouble inserting or threading the dialysis needles.
• Swelling of the patient's access limb Increased venous pressure during treatment,
• Forcing you to turn the blood pump down
• Recirculation
• Extracorporeal system clotting off during treatment Increased bleeding after needles are removed postdialysis
• "Black blood syndrome"
• Decrease kt/v and URR
• Inability to obtain prescribed blood flow rate
• Is caused by injury of the blood vessel lining that scars the blood vessel and creates flow turbulence.
• This leads to overgrowth of smooth muscle cells or aneurysm formation.
• Stenosis may recur after treatment.
• To find venous or arterial stenosis, dye is injected into the vessel. With the dye, any narrowing will show up on an x-ray (fistulogram, venogram)
• It can also be found by color Doppler ultrasound.
• Ultrasound is a non-invasive way to look at blood vessels and blood flow.
• Some cases can be treated with angioplasty, which is an outpatient procedure.
     • The doctor threads a catheter with an inflatable balloon tip into the vessel
     • Once the balloon is in place, he/she inflates it to expand the vessel lumen


Thrombosis
• Formation of a thrombus, or blood clot
• Occurs in all types of a vascular access, but less than 1/6 as often in AVFs than in grafts
• Blood has a number of components ..o stop a wound from bleeding by forming a clot.
     • These include clotting proteins called plasma coagulants and platelets - tiny blood cells that sticr. together to seal off damaged blood vessels.
     • Platelets clump when they are "activated" by contact with damaged blood vessel walls or by turbulence inside a blood vessel.
     • Activated platelets and damaged tissues signal blood clotting proteins to form a strong net of fibers (fibrin).
     • This net traps more platelets and RBCs, so the clot gets more solid as it grows bigger
• A clot may start to form any time there is low blood flow due to low blood pressure, dehydration, or too much pressure on access,
• These conditions let blood pool at a damaged surface, like a needle site.

• In a fistula, blood flow through an area of stenosis may cause enough turbulence to activate platelets, so they stick to the vessel wall.
• Repeated cannulalions also damage vessel walls, causing rough surfaces that activate platelets.
• Early thrombosis is most often caused by surgical problems with the anastomosis or twisting of the blood vessel.
• It can also be caused by stenosis, reduced blood flow due lo hypotension at dialysis, a cardiac arrest, or compression of the vessel.
• The vessel can be compressed after surgery if blood leaks into the tissues causing swelling and
hematoma.
• Hematomas may also form at the site of an infiltration, or if an access is used too soon after surgery.
• Applying too much pressure for too long to the puncture site after treatment may also lead to thrombosis.
• Pressure should not be placed on a puncture site for more than 20 minutes.
• If bleeding lasts longer than 20 minutes, the nurse should look at the heparin dose and check for an access problem, like stenosis.
• Late thrombosis may develop in a fistula that was working. It can be caused by increased turbulence from stenosis.
• Untreated thrombosis can destroy an access
• Thrombosis is most often caused by stenosis and low blood flow.
• Signs of pending access thrombosis:
     • Reduced thrill and bruit
     • Poor blood flow through the access
     • Inability to obtain prescribed blood flow rate
     • Sudden swelling of the hand on the access arm in a patient with a history of stenosis and blood flow problems
     • Abnormally high venous pressure readings during dialysis
     • A high recirculation rate; always check if the needle placement may have had an effect before calling the nephrologist Increased TMP.
• Suspect thrombosis if you feel no pulse or thrill and hear no bruit along the outflow vein.

• Thrombosis in a previously working access often follows stenosis. Early detection and repair of stenosis may help save the access.
• The KDQI Clinical Practice Guidelines for Vascular Access recommend that centers have an access monitoring program. - it helps to improve patient's vascular access outcomes by identifying problems early.
• AVF can be monitored through measurement of dynamic and static venous pressure, access flow measurement, and duplex ultrasound.
• Thrombosis can be treated b surgical, mechanical, or . chemical (use of drug to dissolve the clot) thrombectomy.
• 90% of cases ~ stenosis is the cause of the clot
• This maybe corrected by surgery to revise the access, or angioplasty after the clot is removed.


Patient Actions to Prevent Thrombosis
To avoid thrombosis, patient should:
• Prevent medical staff from using the access or access limb for routine blood draws, IVs, or blood pressure checks
• Feel for the thrill and listen to the bruit daily to ensure patency
• Think about learning how to self-cannulale to reduce the risk of mispuncture

Patient should not:.
• Sleep on the access arm
• Put too much treasured on the puncture site after removing the dialysis needle
Wear tight-fifing clothing or jewelry that squeeze the access arm
• Carry object objects across the arms that compress the access, such as a purse
• Use the access for IV drugs
• Wear a watch on the hand that has a radiocephalic or lower arm fistula


High Output Cardiac Failure
• An AVF can be one cause of high output cardiac failure.
This is a complex condition in which:
     • The fistula brings more blood to the heart
     • The heart works harder, reducing resistance in the arteries
     • Arterial blood pressure falls
     • The drop in arterial blood pressure triggers the renin-angiotensin system
• Patients with high output cardiac failure may have rapid pulses as their hearts try to make up for the extra blood flow (20% or greater) caused by the access.
• They may be short of breath if the blood does not contain enough oxygen.
• Swelling may occur In the hands and fee because return circulation to the hearts poor.
• If untreated, it can cause chest pain, fluid in the lungs, abnormal heart rhythms, and death.
• High cardiac output may also be caused by anemia or heart disease the patient had before the vaacular access
• Prevention is best aimed at treating anemia and creating an access that will not tax the patient's hcart.
• If high output cardiac failure occurs, limiting fluid gain between treatments will reduce the strain on the heart.
• Longer and/or more frequent treatments may help will fluid gains, reducing the strain.
• Medication may also be given to help the heart beat strongly.

• Surgery may be needed to reduce blood flow through the access.
• Surgery is either done either to band the arterial anastomosis or to tie off the fistula.

Dialysis-Related Complications of Fistula

Fistula Complications
• For patients, access problems can lead to access failure, inadequate dialysis, hospital stays, and even early death.
• Access problems also affect the care team. They
disrupt schedules and make treatment more difficult Infection
• Never cannulate an AVF that looks infected.
• The fistula needle can transfer an infection on the skin into the patient's bloodstream.
• This can cause sepsis (blood poisoning) one of the leading cause of death in people on dialysis.

Dialysis-Related Complications of Fistula
Line Separation
• Exsanguination (severe loss of blood) can occur if a needle comes out, the lines come apart, or the fistula ruptures (bursts)
• To keep needles from being pulled out, follow the center's procedure for taping.
• Fasten the bloodlines securely and set the arterial and venous pressure monitor limits so you will know right away if a. problem occurs.
• The air/foam detector and venous and arterial pressure monitors can help prevent exsanguination if they are armed and working.
• But, sometimes a dislodged needle can cause a slow loss of blood over the course of a treatment.
• In this case, the drop in venous pressure may not be enough to set off the alarm - and you may not see the blood if the patient's arm is hidden by a blanket
• If a patient is losing blood through the tubing, turn off the blood pump and clamp the bloodlines.
• Apply pressure to the needle site if the needles were pulled out.
• Oxygen, saline, or blood volume expanders may be needed if a lot of blood was lost.
• If needed, start emergency procedures.


Air Embolism
• Air that enters the patient's bloodstream can stop the flow of blood, much like a blood clot.
• If enough air enters the bloodstream:
• The heart pumps foam instead of fluid blood. This reduces cardiac efficiency and can cause cardiac arrest.
• Bloody foam in the lungs makes it hard to breathe.
• An air embolus in the brain can mimic a stroke.
• Depending on where the air goes:
• the patient may be highly anxious
• have trouble breathing
• become cyanotic (turn blue)
• have vision problems or low blood pressure
• or become confused, paralyzed, or unconscious.
• Newer dialysis machines do not permit alarm overrides.
• If the air/foam detector alarm sounds, look at the venous line to see if any air is present before you override the alarm.
• The air/foam detector should stop the blood pump if there is air in the venous drip chamber.
• If you suspect that a large amount of air entered the venous system, have the patient lie on his side and tell the doctor.
• Lying on the left side decreases the chance that air will travel to the brain and the pulmonary artery.


Tips to Prevent Blood Loss During Dialysis
To prevent blood loss during dialysis:
• Never let patients cover their needles or bloodlines with sheets or blankets. You must always be able to see the access.
• Secure all bloodlines and access connections before you start a treatment, and tape the needles so they can't be pulled loose.
• Don't let blood tubing touch the floor; it could be stepped on and pulled apart.
• Check to be sure that the air/fowl detector and arterial and venous pressure monitors are working before you start a treatment, and that the monitors are armed once dialysis begins.


Infiltration / Hematoma
• An infiltration occurs when the needle tip goes into the vein and out the other side, or nicks the side of the vessel, letting blood escape into the patient's tissue.
• Infiltration is the most common complication of needle insertion.
• It occur less often once staff have more practice placing needles.
• It harms the access, which can lead to access failure.
• For patients, infiltration causes pain, bruising, the need for an extra cannulation, and loss of trust in the staff.
• Blood that leaks into the tissue around the blood vessel (hematoma) makes the area swollen, hard, and sometimes red.
• An infiltrated venous needle will raise the venous pressure, which will set off the venous pressure alarm to stop the blood pump.
• An infiltration of the arterial needle will cause the arterial pressure to become more negative.
• To prevent infiltration, closely follow the needle placement technique and:
• Use a gentle technique
• Do not rush,
• Develop a feel for the least bit of resistance in the vessel.
• Level the needle to the surface of the skin. Advance it slowly up to the hub as soon as you feel a pressure change and can see a flashback of blood in the needle tubing.
• Don't flip the needles.
• Flush the needles with saline after insertion to check for good placement (no pain, swelling, or resistance to the saline flush).
• Use the wet needle cannulation technique.
• Remove a needle that infiltrates before heparin is used.
• If infiltration occurs after a patient receives heparin, the nurse may tell you to leave the needle in place.
• You will then need to insert another one beyond the site of the infiltration (usually above).
• If a hematoma forms, give the patient an ice pack and something to act as a barrier (i.e. washcloth) between the ice and the skin to hold in place during treatment, to help reduce the swelling.
• The patient should keep ice on for 20 minutes, off for 20 minutes, on for 20 minutes, etc.
• Finally, do not subtract the time you spend taking care of a needle infiltration from the patient's total dialysis time.
• Lost minutes lead to inadequate treatment.
• Add the lost time to the end of the treatment to be sure that the patient receives the prescribed dialysis dose.


Bleeding During Dialysis
• May be a minor problem (oozing at needle sites) or a life-threatening emergency (needle falling out with the blood pump running).
• Frequent loss of small amounts of blood during dialysis adds to the risk of anemia, a shortage of red blood cells.
• Do not flip the dialysis needles. This practice causes the hole to stretch until it is larger than the needle size, causing oozing during dialysis.


Bleeding During Dialysis
• Use a back eye needle for the arterial draw to
• eliminate the need to flip the needle.
• Profuse bleeding may suggest a tear in the blood vessel or bleeding from a remote site within the access. Uncontrolled bleeding is a life-threatening situation. Call the doctor right away.


Recirculation

• Occurs when dialyzed blood returning through the venous needle mixes with blood entering the arterial needle.
• The mixing means that already-dialyzed blood goes back through the dialyzer to be cleaned again, while the rest of the patient's blood is not cleared enough.
• Recirculation makes treatment less efficient.
• Recirculation can occur when:
     • The blood flow within the AVF is lower than that in the dialyzer (<300-500 mL.min)
     • The needles are placed too close together.
     • Lines are reversed
     • A stenosis is present
• In severe cases, recirculation will re-clean the same blood so much that it turns dark from lack of oxygen (black blood syndrome).
• Recirculation studies may be done if the delivered dialysis dose drops - as noted by a decrease URR or Kt/v - the blood flow rate drops due to higher venous pressures, or the team thinks stenosis is present.
• These steps can help ensure proper needle placement to prevent recirculation:
     • Palpate the patient's access to find the direction of the flow
     • Assure that the tips of the arterial and venous needles are at least 1.5 inches apart.

Fistula Care Postdialysis



Image Source: dartmed.dartmouth.edu


• At the end of the treatment, you will untape and remove the needles.
• Make sure you have completely removed the needle before applying pressure to the skin - you could cu the patients access if you press too early.
• Apply the right amount of pressure. The goal is to stop bleeding, but not damage the access or stop blood flow through it, which could raise the risk of blood clot.
• Teach your patient how to hold their own sites after a
. treatment.

Tips to Increase Fistula Life
To help an access last longer:
• Use the buttonhole technique or rotate needle sites at each treatment. Do not keep cannulating a fistula in the same general area. This could cause an aneurysm.
• Teach the patient not to permit IVs, routine blood draws, or blood pressure checks on the access arm. A "Save the Vein" card is helpful for patients to carry and give to medical staff if blood draws are needed.
• Keep accurate and detailed records of each treatment. If you see any problems with the patient's fistula, tell the nurse or the doctor

Initiating Dialysis with a Fistula

Wash your hands

• Washing your hands is always the first step before you touch any dialysis access,
• The Occupational Safety and Health Administration (OSHA) requires handwashing and gloves to protect north you and the patient from infections.

Examine the fistula
• You will need to inspect (look), auscultate (listen), and palpate (feel) the access.

Look for:
• Signs and symptoms of infection: Redness, drainage, pus, abscesses, open skin, fever
• Steal syndrome (not enough blood flow to the hand): Pale, bluish nail beds or skin
• Stenosis (narrowing): Swollen access arm, pale skin, small blue or purple veins on the chest wall where the arm meets the body
• Cannulation sites: Scabs from needles, the anastomosis, curves, flat spots, aneurysms (ballooning of the blood vessels) and their width, height, and appearance

Listen for:
• Bruit: The sound and pitch of the "whooshing" noise ( a higher or louder pitch may mean stenosis)
• Deep access location: place the stethoscope flat over the access and listen for the bruit. Then, move stethoscope from side to side and listen for the bruit to stop. This will help you find the exact location of the access.

Feel for:
• Skin temperature: Note warmth (possible infection) or cold (decreased blood supply) :
• Thrill: Should be present and continuous, but not a strong
• Vein diameter: Start at the anastomosis with your thumb and forefinger on either side of the fistula. Is the diameter the same along the whole fistula? If there are aneurysms, how wide are they? Are there any flat spots? The diameter of the vessel needs to exceed the gauge of the needle. How deep is the access? This will determine your angle of needle entry.
• Identify sites for cannulation: stay 1.5 inches away from the anastomosis, keep the needles at least 1.5 inches apart, avoid curves, flat spots, and aneurysms. When rotating sites, avoid prior cannulation sites (scabs).
• Steal syndrome: Cold hand temperature in the patient's access hand (compare with the other hand); have the patient squeeze your hand - note any changes in motor skills.


Assess Blood Flow
• Each fistula should have a strong flow of blood from the artery through the access and into the vein.
• The fistula should have a strong thrill at the anastomosis, as arterial blood is pump by the heart through the fistula.
• You will also need to check the bruit: place your stethoscope on top of the access and listen to the whooshing sound.
• It should be strong and continuous, with each sound linked to the one before.
• A change in the bruit to a high-pitched or louder whooshing may mean that stenosis is present.
• A change in the thrill or in the volume of the bruit can also mean that blood flow through the access is slowing down. This is a sign that a fistula may be clotting.


Prepare Access Skin
• Clean the patient's access site before the needle insertion to keep bacteria from getting into the bloodstream through the skin.
• Staphylococcus aureus, or "staph" infection, is common in dialysis patients because:
     • Patients are at a high risk for infection
     • Many have diabetes
     • There are large numbers of catheters
     • Patients have frequent hospital stays and surgeries, exposing them lo infectious agents
     • Dialysis is a community-based setting

• Clean and prep the patient's skin with a solution of 70% alcohol, 10% povidone iodine, or chlorhexidine gluconate with 70% alcohol.
• Alcohol kills bacteria only when it is wet - use a 60 second circular rub on each site
• Povidone iodine (Betadine®) kills bacteria only after it dries - wait 3-5 minutes
• Chlorhexidine gluconate (ChloraPrep®) with 70% alcohol kills bacteria only after it dries - wait 30 seconds
• Sodium hypochlorite (ExSept® Plus) - the manufacturer recommends you wait 2 minutes before cannulating


Apply a Tourniquet
• Always use a fistula when you insert needles into a fistula, even when the size of the vessels does not seem to need it.
• The tourniquet helps you see the fistula better, holds it in place (prevents rolling), and gives you a better "feel" for cannulation.
• The tighter skin also promotes a "cleaner" entry.
• Apply tourniquet as far from the fistula as you can (just below the armpit) to help distribute pressure evenly along the vein and decrease the risk of inflammation.
• Tourniquets should never be so tight that they cause pain, tingling, or cut off blood flow to the fingers.
• They should only be used for cannulation, not during dialysis.


Insert Needles

• Feel for the depth of the access before you insert your needles into a fistula.
• The angle of entry for a fistula will vary based on the depth of the access.
• The deeper the access, the steeper the angle of entry should be for you to have most of the needle inside the access. This will prevent infiltration if the patient moves the access limb during dialysis.
• The key point to remember about cannulation is that it is a gentle technique.
• Choose your angle of insertion based on the depth of the vein, push the needle through the skin and tissue until you feel a release of pressure, check that you get a flashback (blood in the tubing), drop the angle down, and advance the needle.
• This sequence should be a fluid motion - with no jabbing, digging, or probing with needles.
• Do not "flip" the needles (turn it 180° after it is in the vessel). Flipping the needle can:
• Stretch the needle hole, which can lead to oozing during treatment after the patient is heparinized.
• Tear the lining of the vessel
• Cause infiltration
• Try to leave space beyond the venous needle to place another needle in case the first attempt is not successful or infiltrates.
• The venous needle is usually closest to the heart .
• You may do "wet cannulation" or "dry cannulation".
• Wet cannulation - is done with a saline-filled syringe, and can be useful for hard insertions or patients who clot very quickly.
• Dry cannulation - uses the dialysis needles without saline.

Note: if you cannot insert a needle successfully, find another staff person to do it. Most patients can tell you who has most success cannulating their access.


Antegrade and retrograde needle direction
• The venous needle should always be placed antegrade (in the direction of blood flow).
• This helps prevent turbulence when the blood returns from the extracorporeal circuit.
• It is important to be sure that this needle is "downstream" from the arterial needle to prevent recirculation of the newly dialyzed blood back through the dialyzer circuit
• The arterial needle is so called because it is the one placed closest to the anastomosis and receives blood from the artery.

• This needle can be placed antegrade or retrograde (into the flow of blood)
• Always keep the needle tips 1-1.5 inches apart and stay / at least 1.5-2 inches away from the anastomosis. These rules will prevent recirculation and decreased adequacy.


Rope ladder technique (rotating sites)
• Each time a needle pierces a vein, it makes a hole.
• When you take the needle out, a clot forms to close up the hole until the vessel heals.
• When the patient comes in for the next treatment, you will look for the scabs from the last hole and choose different sites so the first ones can heal.
• This is called rotating sites, or the rope ladder technique.
• Sites are rotated to help prevent aneurysms (weak spots in the vessel wall that balloon out).
• It may seem easier and faster to place needles in the same general area at each treatment, but this weakens the wall of the blood vessel.
• If you spread out the sites, you will reduce the risk of aneurysms along the fistula.
• Patients may ask you to cannulate aneurysms because it hurts less.
• Explain that aneurysms can rupture (break open) because the skin gets very thin; they could lose a lot of blood and need surgery to repair their access.


Buttonhole technique (Constant-site)
• It was first used on an access that had limited surface area for needles.
• Dr. Zbylut Twardowski, who invented the technique, found that it has fewer infections, missed needle insertions, hematomas (bruises), and infiltrations.
• Both arterial and venous needles should be inserted in an antegrade direction to aid hemostasis after needle removal.
• To use this technique, remove the scabs from the last cannulation sites. Moisten the scabs first so they don't break into little pieces. To remove the old scab:
     • Apply saline or alcohol-based gels to a 2x2 gauze pad and lay one over each site, then use antiseptic tweezers.
     • Provide alcohol squares and tape for the patient to take home, and ask him or her to tape an alcohol square over each scab before coming to dialysis.
     • After the scab is gone, prepare the sites.
     • Then reinsert sharp needles at the same angle into the same two holes.
     • Over the course of 3-4 weeks, a well healed scar track/tunnel forms - like a pierced earring hole.
• During this time, the same person should place the needles to be sure the same angle is used each time.

You can download this pdf file for more information regarding buttonhole technique.


• During this time, the same person should place the needles to be sure the same angle is used each time.

• This person can be the patient, since he/she is always there at each treatment.
• Once the scar track/tunnels are formed, blunt needles should be used to avoid cutting the track/tunnel, which can cause oozing during dialysis.

 
Securing the Needles After Insertion

• After the needles are inserted, they need to be secured.
• The butterfly tape technique is a method of securing needles.
• Carefully place a piece of 1 -inch wide adhesive tape, 6 inches or greater in length, under the fistula needle and then fold it so it crosses over the needle side
• Then place a bandage or 2x2 gauze pad over the needles to keep them from moving or pulling out of the access.


Coping with Parents' Needle Fear
• People with physical fear of needles have an involuntary vasovagal response to needles, the sight of blood, surgery, etc...
• First, the pulse speeds up and blood pressure rises
• Then the pulse slows, blood pressure drops, stress hormones are released, and heart rhythms may change
• Patients may become pale, sweaty, nauseated, dizzy, and may pass out.
• People with needle phobia may be able to learn to short-circuit the vasovagal response.
• Some tips that may help:
     • Lay the chair flat to keep blood in the brain so the patient doesn't pass out.
     • With the patient's doctor's permission, have the patient tense the muscles of his/her non-access limbs for 10-20 seconds, relax, then re-tense them until the needles are in. this can temporarily raise the blood pressure and prevent the vasovagal response.
     • Reduce needle pain, using the techniques listed in the next section. Pain is a part of the cause of fear.
     • Teach patients how to insert their own needles. This distracts them from the pain and replaces it with control.

Reduce pain from needle insertion
• The goal is to insert the fistula needles easily and as painlessly as possible, while causing the least amount of trauma to the access.
• Reduce pain from needle insertion " The goal is to insert the fistula needles easily and as painlessly as possible, while causing the least amount of trauma to the access.
• The 3-point technique can help reduce the pain of . needle insertion and aid in successful cannulation.
• Another way to help patients with needle phobia if they have AVF is to use the buttonhole technique, which causes less pain.


The 3-point technique
• First apply a tourniquet to stabilize the fistula vein. To minimize vein movement, place the thumb and forefinger of your non-needle hand on either side of the fistula vein, just above where the needle will go.
• Then, with your pinky or ring finger of (he needle hand, pull the skin taut (tight) and press down on the skin.
• The tighter the skin, the more easily the needle can puncture it, which will reduce pain,
• Pressing on the skin will temporarily block the pain-to-brain, sensation for tip to 20 seconds, giving staff enough time to insert a needle.
• Others ways that patients can reduce pain include:
     • breathing techniques
     • guided imagery
     • listening to music
     • distraction (have the patient in the next chair or a staff talk with your patient while you insert the needles)
     • choice of local anesthetics

• The KDOQI Clinical Practice Recommendations for Vascular Access say that patients who are capable and whose access is suitably positioned should be encouraged to self-cannulate - and the preferred method is the buttonhole technique.


Lidocaine injection
• An injection of I % intradermal lidocaine can be used to numb the tissue.
• Tlie site must be propped first.
• Use a separate 1 -cc or tuberculin syringe and needle for each site.
• Inject the I idocainejust below the skin into the tissue above the graft or fistula
• Never inject lidocaine into the patient's fistula vein; this would allow it to enter the bloodstream.
• The lidocaine will form a bubble or wheal just under the skin.
• Lidocaine bums, so only a small amount should be used.
• The lidocaine may leak back out from the injection Site and/or bleeding may occur at the injection site.
• Use a sterile gauze pad to wipe away any leakage or bleeding.

Note: Because lidocaine is injected with needles. It may not be helpful for patients who have needle fear.


• Lidocaine is a vasoconstrictor that can make the fistula vein smaller in diameter and pull it a little deeper in the skin. This may make cannulation more difficult.
• Patients whose fistula vein is very close to the skin's surface may have less pain when needles are inserted without lidocaine,


Ethyl chloride spray
• Can be used to numb the skin.
• The spray creates a cold feeling.
• It does not numb the tissue under the skin, so a patient with a deep access will still feel the needle enter the tissue and will feel pain.
• The site must be cleaned by the patient, sprayed, and the prepped by the staff prior to needle insertion


Topical anesthetics
• Gels or creams that numb the skin
• They must be applied to the skin, then wrapped in plastic wrap at home by the patient at least an hour before the treatment.
• They work by contact time, not by the amount applied.
• In order for the top 3mm of tissue to be numb, apply the cream 60 minutes before treatment.
• If you want the top 5mm of tissue to be numb, (for deep accesses) have the patient apply the cream 120 minutes before treatment.
• Some examples are:
     • Over-the-counter Lcss-n-pain™ (4"/o lidocaine)
     • Over-the-counter L.M.X.® (4% lidocaine)
     • Over-the-counter Topicaine® (4% or f% lidocaine)

• At the center, the patient takes off the plastic wrap and washes off the cream.
• Remind patients to wash their hands after putting on the cream and to keep their hands away from their eyes to prevent damage to their mucous membranes.
• Like injected lidocaine, the creams cause vasoconstriction of the fistula.
• At the end of the treatment, you will untape and remove the needles.
• Make sure you have completely removed the needle before applying pressure to the skin - you could cu the patients access if you press too early.
• Apply the right amount of pressure. The goal is to stop bleeding, but not damage the access or stop blood flow through it, which could raise the risk o< blood clot.
• Teach your patient how to hold their own sites after a treatment.

Assessing Maturity of a Fistula

Assessing Maturity of a Fistula

• Look for signs of infection - redness, drainage or abscess formation
• Look for signs of wound healing of the surgical incision
• Feel for a thrill - it should be continuous and feel like purring or vibration, but not a strong pulsation.
• Feel the diameter of the vessel - it should start growing larger immediately after surgery and the growth should be evident within 2 weeks. Note any flat spots.
• Listen for a bruit - the pitch should be low, and one sound should connect to the next sound.
• After the first week, apply a tourniquet and feel for firmness of the fistula vein; this will tell you that the vessel walls are getting thicker/stronger.
• Dialysis patients should have a post-op visit 4-6 weeks after surgery.
• To cannulate a new AVF, smaller needles (17-gauge) and low blood flows (200-250ml/min) should be used for the first week of treatment.


Wash your hands
• Washing your hands is always the first step before you touch any dialysis access,
• The Occupational Safety and Health Administration (OSHA) requires handwashing and gloves to protect north you and the patient from infections.


Examine the fistula
• You will need to inspect (look), auscultate (listen), and palpate (feel) the access.

Pros & Cons of Fistula

Pros

• The AVF is the "gold standard" for hemodialysis access
• It lasts longest and has the fewest problems, including
infection.

Cons
• The main disadvantage of an AVF is how long it can take to mature: 4-6 weeks or more.
• Some fistula also fail to mature at all, a problem called early or primary failure.
• A fistula may not mature if:
     • The anastomosis is too small, so less blood flows into the fistula
     • A stenosis develops at the inflow between the anastomosis and the fistula
     • Side veins off of the AW (accessory veins) reduce pressure in the fistula, so it does not arterialize.
     • The vessel chosen by the surgeon was too small (<2 mm)