St George Hospital Renal Department Internal Only

Transcription

1 RENAL VASCULAR ACCESS CANNULATION POLICY AND PROCEDURE SUMMARY: A functioning arteriovenous fistula (AVF) or arteriovenous graft (AVG) is paramount in the maintenance of regular and optimal haemodialysis treatment (Ball, 2005). Haemodialysis nurses are ideally placed to monitor and maintain vascular access patency with regular physical assessment and by implementing correct cannulation techniques. Prompt referral to the Vascular Access CNC (VAN) and to radiological or surgical intervention is required to preserve the life line of the patient. Fistulas are not to be cannulated within six weeks of creation to allow vessel maturation (K/DOQI, 2006). Although K/DOQI (2006) guidelines suggest AVG can be cannulated after 2 weeks of placement, the vascular surgeons at St George Hospital recommend waiting at least 4-6weeks before cannulation. Flixene grafts however, can be cannulated within 72 hours (Atrium 2008). The VAN will liaise with the vascular surgeon regarding optimal cannulation timing for each access. Expected outcomes: The RN or EN performing the procedure meets the requirements for limitations for practice (see below). Uncomplicated insertion of haemodialysis cannulae with minimal trauma and pain for the patient. Adequate blood flow to achieve optimal dialysis. The nurse competently solves problems associated with cannulation. Maximum preservation of access. To decrease the incidence of hospitalisation and complications such as haematomas or infection from needle trauma. Limitations for practice: The nurse has knowledge of The principles of dialysis The principles of asepsis Access for haemodialysis The nurse has completed the Renal Cannulation Competency including practical and theory components. The practical component involves observation of cannulation by a competent nurse, instruction in the assessment and cannulation of AVF/AVG s and cannulation under supervision until the preceptor is confident that the nurse is competent and safe to practice. The EN is only to attempt cannulation on patients allocated by a RN. The EN is to refer any problems regarding cannulation to the supervising RN. The cannulation of a new mature access should be only performed by a skilled nurse in order to minimize the risk of trauma.

2 PROCEDURE: 1. Equipment Protective gown and face shield or goggles Clean dressing trolley Dressing pack 10ml syringe 20ml syringe 3ml syringe Drawing up needle 25g needle Cannulae x 2 as per the patient s care plan NaCl 0.9% 10ml ampoule x 1 Heparin 5000 units in 5ml ampoule Lignocaine 2% 2ml ampoule Sterile gloves Tape 2% Chlorhexidine swabs x 2 or Betadine if the patient is allergic to Chlorhexidine as indicated on the care plan Packet of gauze 2. Preparation Record and document patients weight, BP, pulse, temperature and respiratory rate. Advise patient to wash their fistula/graft site with antimicrobial soap prior to cannulation to minimise bacteria on the skin before inserting needles. Check the patency of the patient s fistula or graft by listening for a bruit and palpating for a thrill and report to VAN/MO if bruit/thrill are absent. Assess patient s access for signs of infection and report to VAN/MO if present. Establish the direction of blood flow and appropriate cannulation sites. Ensure the patent s arm is well supported on either a pillow or the bed/chair and place protective sheet under patient s arm or leg. Apply tourniquet loosely to the arm if required (AVF only). Put on protective gown and face shield or goggles. Identify your patient and sign the patient s addressograph label to acknowledge you have the correct patient. 3. Procedure 1. Attend a procedural hand wash for 60 seconds. 2. Clean trolley with detergent. 3. Gather equipment 4. Attend a procedural hand wash for 60 seconds 5. Prepare equipment on a general aseptic field; attach required tape to side of trolley. 6. After two (2) RN s have checked the Heparin and signed the IV medication label, draw up the required amount of heparin (as per the patient s care plan)

3 into a 20ml syringe, attach to the heparin infusion line, prime line, clamp line and place syringe into the heparin pump syringe driver. Attach the signed blue IV label to the 20ml syringe. 7. Perform a surgical hand wash for 3 minutes with antimicrobial soap and don sterile gloves 8. Place sterile drape underneath cannulation limb 9. Maintaining an aseptic non-touch technique, clean cannulation area in a circular motion from the centre outwards, with 2% Chlorhexidine swabs (one swab per site) or with Betadine if patient has a known sensitivity to Chlorhexidine. Allow the antiseptic is dry. 10. Prepare 10ml NaCl 10ml syringe. 11. Draw up 2% Lignocaine into the 3ml syringe and attach 25g needle if required. 12. Tighten tourniquet on the patient s arm the patient can do this if able (Rationale: To engorge the vessel and to assist with stabilization of the vessel to be cannulated.) Do not use tourniquet for AVG (Rational: The AVG is a firm structure). 13. Maintaining an aseptic non-touch technique, position Lignocaine needle intradermally and draw back a little to ensure the needle is not in the access. Warn patient of the stinging sensation of Lignocaine and inject no more than 0.5ml under the skin on top of the vein at the cannulation site (a small raised lump will usually be seen under the surface of the skin). Patients with topical anaesthetics such as Emla patches should be educated on where to place patches and should put patches on at least 60 minutes prior to the cannulation. Give the patient an option to have no local. 14. Examine cannula and check it has a functioning clamp, the cap is on and there are no manufacturing faults. Leave the clamp on the cannula open and hold the cannula bevel side up and remove the needle cap. 15. Use the non cannulating hand to render the fistula still and assess the direction and depth of the vein at the same time. An effective way to do this is to stretch the skin on both sides of the vein with the thumb and index finger while pressing on the vein with the middle finger or use your thumb and index finger of your non cannulating hand on either side of the vessel, to help stabilise the vessel and prevent movement. 16. Maintaining an aseptic non-touch technique and using a degree angle for fistulas and a 45 degree angle for deep grafts, insert the cannula through the same puncture site as the Lignocaine. A flashback of blood should be visible once the needle is in the access. Once the bevel of the cannula is inserted, level out the cannula to an appropriate angle and advance slowly up to the needle hub. 17. Secure the cannula to the patient s skin by taping the wings individually. Use caution when taping needles as an improper needle flip or taping can cause infiltration. 18. Loosen the patient s tourniquet (the patient can do this if able). 19. Loosen or remove cannula cap to allow the blood to flow back to the end of the cannula tube. Take blood if required, then flush with 5ml of saline while observing for pain or swelling around the cannula area. 20. Reposition or rotate the cannula if required. 21. Cover the puncture site with a sterile gauze and tape. 22. Repeat procedure for the second cannula.

4 23. Remove gloves and perform hand hygiene. 24. Discard sharps and waste appropriately. 25. Clean trolley and perform hand hygiene. GUIDELINES: 1. If a nurse has had two unsuccessful attempts at cannulation, assistance should be sought from another experienced member of staff. New staff should call for assistance after the first failed cannulation. 2. Never recannulate with the same cannula. 3. Never cannulate into an infected area of an access. 4. To avoid recirculation when the same vein is used, venous cannula should be at least 5cm proximal to the arterial cannula (measured from hub to hub) when they are placed in opposite directions. They should be 5-8cm apart when placed in the same direction. Never place the arterial and venous needles towards each other as this will result in recirculation. 5. The venous cannula should always be inserted to point towards the direction of the heart (Rationale: Venous needle in the same direction as the blood flow will prevent excessive pressure at the needle site and hence will prevent turbulence when blood returns from the extracorporeal circuit (Ball, 2005). 6. An antegrade arterial cannula (pointing in the direction of the blood flow) is recommended for a new fistula as this prevents the needle entering the anastamosis site. 7. To avoid trauma, the cannula tip or vein entry point should be at least 3 cm away from the anastamosis site. 8. When cannulating an AV loop graft, cannulas should be inserted in either side of the loop and the flow direction can be determined by pressing between the two cannulae. Blood should continue to pulsate within the arterial cannulae once the centre of the graft is compressed. 9. Needle site rotation (the rope ladder technique) is essential in the preservation of AV access as it prevents pseudoaneurysm formation in fistulas. Rotation also helps promote the even maturation of an AVF and prevents AVG degradation. Buttonhole technique is recommended for native AVF that have limited area for cannulation (Brouwer, 1995). 10. If resistance is felt when the cannula is being advanced, stop, pull back and redirect the angle. When in doubt, always ask an experienced staff member for help. 11. Swelling and/or pain are usually indicative of back or side wall infiltration ( blown / bombed ). The cannula should be removed and pressure should be applied to the cannula site as well as the area of infiltration. Placing a cold pack on the area will help to reduce pain and bruising. Heparinoid cream can also be applied to help reduce bruising. 12. Further cannulation after infiltration should be as far away from the infiltration site as possible. In a venous needle site infiltration, the second cannula should be placed above the area in order to avoid a high venous pressure or dislodging the clot formed at the site of the punctured vessel wall. In an arterial needle site, the second needle should be inserted below the area of infiltration to help avoid arterial insufficiency occurring (sometimes this is not possible when the bomb is too close to the anastamosis).

5 13. Avoid cannulating any bruised areas as this may dislodge clots into the vascular system and may cause clotting of the cannula (Brouwer, 1995). 14. DO NOT attempt to cannulate if the AVF/AVG is not patent (K/DOQI, 2006). 15. Document any issues with cannulation. REFERENCES: Atrium Medical Corporation (2008). APHECS II. Ball L, Dillon T, Dinwiddie L. & Holland J. (2005) Vascular Access, third Edition. Module 5 pp Medical education institute Brouwer DJ. (1995) Cannulation camp needle cannulation training for dialysis staff. Dialysis and Transplantation 24 (11) pp Daugirdas J, Blake P, & Ing T. (2001) Handbook of Dialysis, 3 rd Edition. Lippincott, Williams & Wilkins: Philadelphia. NKF K/DOQI (2006):