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Friday, November 5, 2010

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.

Initiating Dialysis with a Fistula - Related Hemodialysis Article


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