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Cannulation Camp: Basic Needle Cannulation Training for ...

  1. 1. Reprinted with permission from Dialysis & Transplantation, Vol. 24, No. 11, 1995. Deborah J. Brouwer, RN, CNN Cannulation Camp: Basic Needle Cannulation Training for Dialysis Staff This article reviews the basic skills needed by all dialysis staff to correctly cannulate an AV fistula or PTFE graft. Ways to identify the two types of accesses and to determine the direction of bloodflow are described. Access site determination and preparation, needle placement and direction, and various cannulation techniques are explained and supported by illustrations. Complications are examined, as are possible treatments and ways to prevent recurrences. H ow did you learn to cannulate a The flow direction of either a fistula or dialysis access? Most practicing graft must be correctly identified in order to nephrology nurses and techni- ensure proper needle cannulation. Most cians - myself included - had on-the-job fistulas flow from the distal end of the limb training. We observed our preceptor toward the venous return. The direction of cannulate different patients who had either flow of a particular fistula can be easily grafts or fistulas, and then were handed identified by locating the arterial the needles for our first cannulation anastomosis engorgement prior to attempt. placement of a tourniquet. Another method Very little nursing research and/or is to listen for the bruit and feel for the literature is available for a preceptor to use thrill, which should be noticeably stronger when teaching the art of needle at the arterial end of the fistula. cannulation. The purpose of this article is to provide current nephrology staff with a basic knowledge of needle cannulation, information which may then be passed on to new staff entering the nephrology field. Step I: Identify the Type of Access and Direction of Bloodflow The preferred dialysis access is the arteriovenous (AV) fistula. This is due to its high patency rate and the strong ability of The illustrations for this the puncture sites to heal. However, due to article were provided by vascular limitations, only about 30% of all W.L. Gore & Associates, Inc. dialysis patients have working AV fistulas.1 The majority of the The most common AV fistula is one illustrations were adapted with permission from the connecting the radial artery to the cephalic Gore publication, Vascular vein, created at the patient's wrist. A fistula Access for Hemodialysis-IV. can also be created in the upper arm, connecting the brachial artery with the axillary vein or another upper arm vein, all Deborah Brouwer is of which lead to the subclavian vein. A leg with Dialysis Clinic, Inc., fistula can also be created in patients with Pittsburgh, Pennsylvania limited access options. Figure 1. Regular or “blue thumb” graft. Page 1
  2. 2. Reprinted with permission from Dialysis & Transplantation, Vol. 24, No. 11, 1995. Cannulation Camp Unfortunately, the flow direction stronger bruit and thrill can be within an implanted polytetrafluo- considered to be the arterial limb. roethylene (PTFE) graft cannot be Next, the graft can be so easily identified. This is because cannulated with two needles and a graft can be placed in any the blood flashback observed. location where an artery and vein When the mid-graft area is can be connected. The traditional compressed, the arterial needle graft sites - i.e., the lower arm (loop flashback should remain visible, graft) and upper arm (straight graft) while the venous needle flashback - have now been supplemented by should greatly diminish or straight or loop grafts in the leg, disappear. groin, abdomen, chest, or neck. As If a graft is to be used prior to such, the direction of the bloodflow the clearance of all residual may not be apparent by visual operative edema, it may be difficult inspection alone. to palpate the graft or to compress Cooperation with the vascular the mid-graft segment in order to surgeon in obtaining a drawing or show a difference in blood Figure 3. Direction of bloodflow description of the bloodflow flashback within the arterial and determines needle placement. direction is the best way to ensure venous needles. In this case, proper use of the access. In the noting the venous pressure and with the flow direction. In this absence of such records, several pre-pump arterial pressure may regard, grafts can be described as techniques can be used to assist in determining the bloodflow being either a regular or "blue determine bloodflow direction. As direction. To accomplish this, the thumb" graft, or a reverse or "red previously mentioned, the most needles are connected to the thumb" graft. A "blue thumb" graft commonly used technique is to dialysis circuit, a 200 ml/min blood- is when the arterial inflow is on the listen to the bruit and feel for the flow is achieved, and the mid-graft limb of the graft medial to the thrill at both ends of the graft; the region is lightly compressed. If the midline of the body or heart (see end with the stronger bruit and thrill needles have been correctly Figure 1). A reverse or "red thumb" is assumed to be the arterial limb. connected arterial-to-arterial and graft is one in which the arterial To confirm this assumption, the venous-to-venous, the venous inflow is on the limb of the graft mid-graft area can be lightly pressure will fall due to the distal to the body midline or heart2 compressed to impede the decrease in bloodflow to the (see Figure 2). Of all dialysis loop bloodflow; again, the end with the venous limb when the mid-graft grafts, approximately 80% are region is compressed. If the arterial regular, with the remaining 20% bloodline has been incorrectly being reverse.3 The red or blue connected to the needle in the thumb concept can be easily taught venous limb of the graft and the to patients so that they may venous bloodline to the needle in understand the bloodflow direction the arterial limb, the pre-pump within their own access. arterial pressure will change to a more negative number and the venous pressure will increase. This is a result of the mid-graft compression causing the arterial bloodline connected to the venous limb of the graft to work harder in order to receive the inflowing blood; the venous pressure increases due to the compression of the venous outflow track. If this occurs, the bloodlines should be reversed, the mid-graft compression repeated, and a fall in the venous pressure should then be observed.2 Once the direction of the Figure 4. Venous needle always points bloodflow is determined, the toward the venous return. Arterial needle Figure 2. Reversed or “red thumb” graft. patient's chart should be marked may point in either direction. Page 2
  3. 3. Reprinted with permission from Dialysis & Transplantation, Vol. 24, No. 11, 1995. Cannulation Camp placed in the same direction on the same limb, for if they are placed too close, such as less than 3" apart as measured from hub to hub, the needle bevels may touch or be too close and lead to recirculation2 (see Figure 7). Both antegrade and retrograde cannulation can be used with AV fistulas, as well. Antegrade cann- The needle sites selected for ulation can be used to cannulate cannulation must be properly Figure 5. Needle placement if only one near the arterial anastomosis of an prepped in order to prevent portion of the graft can be used for access without the needles enter- infection. Proper washing of the cannulation. ing the anastomosis site. This is patient's access area with water Step II: Needle Site particularly helpful with newly and an antibacterial soap should be created AV fistulas that are not fully done prior to cannulation. If the Selection matured, as the antegrade patient is unable to wash his or her Since the placement and direction cannulation can sometimes provide own access area, the dialysis staff of the access needles can vary, a higher bloodflow with less can use a washcloth soaked with needle site selection should be bloodline collapse or line sucking, antibacterial soap to cleanse the determined before skin preparation and a better pre-pump arterial area. A ready-to-use antibacterial and needle cannulation are per- pressure. towel or prep pad can also be formed. Needle site placement must used. It is the direction of the always take into account needle After cleansing, the sites bloodflow that determines the site rotation. This is true for both should then be prepped with either needle placement. This is because AV fistulas and grafts. Proper Betadine or alcohol. Once applied, the venous needle must always needle site rotation will extend the Betadine must be allowed to dry point toward the venous return. The life span of the access by before it is an effective antiseptic, arterial needle, on the other hand, preventing pseudoaneurysm form- whereas alcohol must be used in a may point in either direction (see ation, or "one-site-itis" (see Figures liquid state to be effective.5 During Figures 3 and 4). 8 and 9). Additionally, fistulas that the preparation of the access sites, The terms antegrade and are cannulated throughout the universal precautions, including the retrograde are used to describe the entire fistula will mature more wearing of gloves, must always be direction of the arterial needle. evenly, and grafts so cannulated used to prevent the spread of Antegrade cannulation has the will not develop flat, mushy areas infection. arterial needle pointing in the caused by repeated cannulation in direction of the bloodflow, that is, the same spots, which do not allow Step IV: Local Anesthesia toward the venous limb. Retro- for fibrous tissue formation and, If the patient experiences grade cannulation has the arterial subsequently, lead to the develop- discomfort during cannulation, the needle pointing toward the arterial ment of large holes (Figure 9). administration of an intradermal anastomosis.4 Either of these cann- A patient record of the cann- injection of lidocaine may be used ulation techniques can be used, ulation sites-such as an illustrated immediately prior to the needle with the choice being based on unit bedside cannulation chart and a cannulation. Other agents, such as practice. cannulation rating chart-can be Chloroethane (ethyl chloride) When complications such as used to help ensure full needle site spray, or lidocaine 2.5% with infection or recent surgical revision rotation (see Figures 10 and 11). prilocaine 2.5% (Emla Cream), can dictate that only one limb of a loop graft can be used, the needles may also be used to prevent discomfort be placed on the same side of the Step III: Skin Preparation from the cannulation. Because of graft, with one needle placed the potential for further discomfort upward and the other downward, brought on by additional needle as shown in Figure 5. When that is sticks, the choice of using lidocaine the case, the needles must always as a local anesthetic for needle be at least 1" apart, as measured cannulation should be at the from hub to hub, in order to prevent request of the patient; however, its recirculation (see Figure 6). use should be avoided in the case Care should be taken in those of a deep or edematous graft-which cases where the needles are may occur with newly created Page 3
  4. 4. Reprinted with permission from Dialysis & Transplantation, Vol. 24, No. 11, 1995. Cannulation Camp skin, which facilitates cannulation through the skin, subcutaneous tissue, and the graft wall or fistula vessel wall. The needle should be held at a 20- to 35-degree angle for AV fistulas, and at approximately a 45- degree angle for grafts.6 Once the needle has been advanced through the skin, subcutaneous tissue, and graft or fistula wall, the blood flashback should be visible. Continue to advance the needle no greater than 1/8 of an inch and then rotate the needle 180 Figure 8. “One-site-itis” due to repeated needle puncture in the same location, degrees6 (see Figure 13). The the result of poor needle site rotation. needle bevel is rotated to help prevent a "back wall" or posterior PTFE grafts-where the injection of to 500 ml/min are now standard in wall infiltration, which can occur if lidocaine prevents palpation and many dialysis units). the needle's bevel tip accidentally easy cannulation. Pre-pump arterial pressure punctures the bottom of the graft or When using lidocaine, the monitoring can help determine if fistula (see the discussion under minimal amount (0.2 cc) should be the needle gauge needs to be "Cannulation Problem-Solving"). used, and the patient should be increased. If the arterial pressure The needle should then be warned that the injection might falls lower than -200 to -250 leveled out (i.e., placed flat against burn or sting. Care must always be mmHg, the needle size should be the skin) and then advanced slowly taken to ensure that the lidocaine is increased (i.e., a smaller gauge up to the needle hub (see Figure injected only into the tissue on top number should be used). However, 14). of the access and never into the this decision should first be graft or fistula itself. discussed with the dialysis staff Step VII: Securing and the nephrologist. the Needle Step V: Needle Selection The wings of the fistula needle can The specific gauge of the needles Step VI: Cannulation be secured by using a butterfly used for cannulation should always Technique tape technique. A piece of 1"-wide be ordered by the nephrologist in The needle should be held by the adhesive tape 6" or greater in order to ensure that an adequate wings, with the bevel of the needle length is carefully placed under the bloodflow rate is achieved for the facing upward for the cannulation fistula needle wings and then proper delivery of the dialysis (see Figure 12). This places the folded so that it crosses over the or prescription. The length of the cutting edge of the needle on the needles, on the other hand, may be altered by the dialysis staff in order to reach, for instance, deep grafts such as those found in the upper arm of an obese patient, where a 1" needle may not be long enough to cannulate the graft or advance far enough into the graft to prevent movement. In that case, a 1 1/4" needle may be helpful. The needles used should always have a back eye to ensure that the optimal flow is achieved. Additionally, the standard 16-gauge needle may need to be increased to a 15- or 14-gauge in order to achieve bloodflows greater than 300 ml/min (bloodflow rates of 350 Figure 9. A pseudoaneurysm caused by “one-site-itis,” which can lead to graft failure. Page 4
  5. 5. Reprinted with permission from Dialysis & Transplantation, Vol. 24, No. 11, 1995. Cannulation Camp procedure, a 2x2 vessel, as this could cause further gauze pad may be damage to the vessel wall. placed under the Should an infiltration occur, needle wings to cannulation with another needle correct the needle should be performed at a spot as angle. Care must far away from the infiltration site as be taken with any possible. If the infiltration has been change to the caused by a venous needle, the needle position so second needle should be placed that infiltration into above the infiltration site. However, the back or side this is not always possible, and if wall of the graft or the venous needle must be placed fistula is avoided. below the infiltration site, it should be placed 1 1/2" to 2" away from the site to prevent the needle tip Step VIII: from dislodging the clot formation Cannulation at the site of the vessel wall Problem- infiltration. Following the second Solving cannulation, careful flushing of the Figure 10. Bedside cannulation chart, showing dates and If resistance is felt venous needle, along with a slow locations of prior puncture sites. at any time during restart of the dialysis blood pump, needle site. An adhesive bandage needle advance-ment or needle should be performed in order to or a 2x2 gauze pad is then placed position change, the needle should monitor the infiltration site for an over the needle and secured by be pulled back and the angle increase in hematoma size. another 6"-long piece of tape. redirected. When in doubt, always Care must be taken with all The needles must be secured ask a colleague for help. needle cannulations in order to in place in order to prevent A back or side wall infiltration prevent infiltrations. A severe accidental dislodgment or move- can occur with any needle infiltration, such as a posterior or ment of the needles within the cannulation. If an infiltration does back wall infiltration in a PTFE access, and care must be taken to occur prior to the patient receiving graft, can lead to the formation of a monitor the needles for inadvertent heparin, the needle should be large hematoma and subsequent movement during the dialysis pulled out and digital pressure graft compression and/or graft treatment. This movement within applied to the exit site by placing thrombosis. While the use of the the graft or fistula can result from two fingers along the access- 180-degree needle rotation, or the patient rotating or bending his extending over a minimum of a 1" "flip," discussed earlier is not or her access limb, which may lead span-in the area of the infiltration. necessary to correctly cannulate a to poor bloodflow and/or needle Unfortunately, it is difficult to control PTFE graft or fistula, it may help infiltration. back or side wall bleeding because decrease the chance of a severe Special care must be taken direct pressure to the puncture site infiltration. When training new staff, with deep or edematous grafts is not possible. because the needles are more If the patient has already prone to shift after the cannulation. received heparin, the infiltration site With edematous grafts, this results must be carefully assessed to see from the edema being displaced if the needle should be pulled out following the application of or left in place with ice applied over pressure during the palpation and the site until the dialysis treatment cannulation of the graft, with the is completed. If the infiltration site edema subsequently returning to remains stable with no increase in the subcutaneous tissue surr- the size of the hematoma, the ounding the cannulation sites and needle can be safely left in place causing the movement of the and pulled out at the end of the needles. With deep grafts, move- treatment. If, however, the ment can occur simply because of hematoma increases in size, the the amount of tissue pressing needle should be removed and against the needle. digital pressure applied. Never Should any movement of the apply pressure to an infiltration site needles occur during the dialysis while the needle is still in the Page 5
  6. 6. Reprinted with permission from Dialysis & Transplantation, Vol. 24, No. 11, 1995. Cannulation Camp this technique may be particularly movement of the needles. Each that bloodflow occlusion (which helpful in preventing the staff needle is then withdrawn slowly, at could possibly cause thrombosis of member from advancing the needle a 20-degree angle, until the entire the access) has been averted. A into and through the vessel in one needle has been removed. To family member can be trained to smooth, uncontrolled movement. prevent damage to the vessel wall, assist patients who are unable to In a recent article by Hartigan,4 digital pressure should not be maintain compression of their own the question is raised as to whether applied during needle removal.6 If needle sites. flipping the needle may, in fact, the needle bevel has been rotated actually cause additional trauma to 180 degrees during insertion, there the intimal of the access. However, is no clinical evidence or research Hartigan acknowledges that no that supports the re-flip or re- controlled studies have been rotation of the needle before it is performed to address the risks and withdrawn. benefits of flipping or not flipping Once the needle has been the needle during cannulation. removed, mild digital pressure Dialysis staff, therefore, should should be applied to the needle exit evaluate the infiltration problems sites of both the skin and graft or that occur within their own practice vessel wall (see Figure 15). A and appropriately adjust cannu- gauze pad should be held over the lation techniques in order to sites with constant pressure, decrease the number of infil- without peeking, for 10 to 15 When using topical clotting trations. minutes. To ensure that both the agents, care must be taken to skin and vessel needle exit sites ensure that the cannulation site has Step IX: Removal are being compressed, the patient clotted and not just the needle exit of the Needles should place both the index and site of the skin, for if hemostasis is Proper needle removal is as middle fingers over the gauze pad, not achieved, blood may leak out important as is proper needle with the thumb wrapped around the into the subcutaneous tissue cannulation, for if the needles are limb like a "C" clamp. This will keep surrounding the graft. This often improperly removed, damage to the the patient from shifting the happens when the patient stands vessel wall can occur, whether with compression off of the exit sites, up to exit the dialysis unit, at which PTFE grafts or AV fistulas. which would permit bleeding. The time the cannulation site can begin The tape should be carefully bruit and thrill should continue to be re-bleeding if the clot over the skin removed post-dialysis to prevent discernible above and below the puncture site is dislodged. If re- compression sites, an indication bleeding is not visible from the skin puncture site but has occurred subcutaneously, ecchymotic areas will be present when the patient returns for his or her next dialysis treatment. Step X: Discharge Dressing and Assessment Always discharge the patient from the unit with an adhesive bandage or gauze pad over the cannulation sites. Tape may be used to secure the pad but should not be so tight that it compresses the lumen of the access. Before the patient leaves the unit, assess and document the quality of the bruit and thrill. If the bruit or thrill is greatly decreased or absent, the patient must not be discharged until the nephrologist has been notified. And remember, a Doppler-positive bruit does not Page 6
  7. 7. Reprinted with permission from Dialysis & Transplantation, Vol. 24, No. 11, 1995. Cannulation Camp always equate with a positive bruit and thrill. CONCLUSION Nursing research is needed to better evaluate all cannulation procedures. Our goal should be to safely cannulate any access without causing unnecessary damage to the patient's lifeline. As such, the basics of needle cannulation must be openly discussed among all patient care staff members. We must work toward having all dialysis staff members understand and master the basics of vascular access. The fundamental principles of vascular access should be used to help train future dialysis staff members in order to improve the quality of care that future dialysis patients will receive. We must continue to gain knowledge in this important area through nursing research and education. . References 1. Fan PY, Schwab S. Vascular access: Concepts for the 1990s. J Am Soc Nephrol 3:1, 1992. 2. Brouwer D. Hemodialysis: A Nursing Perspective. In: Vascular Access for Hemodialysis - IV (a W.L. Gore publication). Henry M, Ferguson R (eds.). Chicago, IL: W.L. Gore & Associates, Inc., and Precept Press, 1992. 3. Raja RM. Vascular access for hemodialysis. In: Handbook of Dialysis. Daugirdas JT, Ing TS (eds.). Boston, MA: Little, Brown & Co., 1994. 4. Hartigan M. Vascular access and nephrology nursing practice: Existing views and rationales for change. Advances in Renal Replacement Therapy 1(2):156-157, 1994. 5. Perkins JJ. Principles and Methods of Sterilization in Health Sciences (2nd Ed.). Springfield, IL: Charles C. Thomas Publishers. pp. 337-338, 1969. 6. Lancaster LE. Core Curriculum of Nephrology Nursing. Pitman, NJ: American Nephrology Nurses' Association, pp. 266, 272, 1995 Page 7

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