SUCCESSFUL VASCULAR ACCESS MANAGEMENT FOR HOME HAEMODIALYSIS: A PRACTICAL APPROACH

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1 CLINICAL PRACTICE SUCCESSFUL VASCULAR ACCESS MANAGEMENT FOR HOME HAEMODIALYSIS: A PRACTICAL APPROACH Annemarie Verhallen Dianet Dialysis Centers, Utrecht, The Netherlands Verhallen A. (2013). Successful vascular access management for home haemodialysis: a practical approach. Journal of Renal Care 39(Suppl. 1), SUMMARY Background: The literature in the field of access management in relation to home haemodialysis (HHD) was reviewed. Findings: One of the greatest benefits of HHD is the possibility for high dose dialysis. There is, however, concern about its adverse effects on access survival. Furthermore, for the patients, self-cannulation is often the biggest obstacle for HHD. Both problems might be resolved by applying a single needle dialysis technique or, in case of arterio-venous fistulae, using the buttonhole (BH) method. As for the BH method there is one limitation the elevated risk of life-threatening infections. However, in none of the trials referred to in this paper, the BH method was abandoned, probably due to the implementation of successful, problem-tackling measures. Conclusion: Continued training and re-training of staff and patients is vital to gain and maintain a wide understanding of successful vascular access management. KEY WORDS Access survival Buttonhole technique High dose dialysis Nocturnal home haemodialysis Selfcannulation INTRODUCTION Vascular access management is the most important challenge of the entire dialyses procedure, both in the hospital and home setting. To perform a safe and manageable home dialysis, a wellfunctioning access which is easy to cannulate is vital. Problems with access can cause a lot of undesirable stress in the home situation and, as a last resource, a transfer back to the hospital BIODATA Annemarie Verhallen currently works as a coordinating home haemodialysis nurse at Dianet Dialysis Centers, Utrecht, The Netherlands. Her activities have been focused on improving the quality of life of HHD patients. She participated in the Dutch nocturnal HHD project and introduced the buttonhole method in the Netherlands. CORRESPONDENCE Annemarie Verhallen, Dianet Dialysis Centers, Brennerbaan 130 Utrecht, 3524 BN, The Netherlands Tel.: þ a.verhallen@dianet.nl might be necessary, thus compromising the quality of life and independence of the patient (Brouwer et al. 2010). Cannulation is often the central point of focus for patients and nurses alike. Cannulation can be painful, and, if not applied correctly, there are a lot of severe short- and long-term complications looming. Once the needle is comfortably placed in the correct position, the dialysis procedure itself will probably go without problems and everybody involved can relax. However, there are three main differences between access management in hospital compared with the home situation: 1. High dose dialysis, i.e. short daily haemodialysis (SDHD) or nocturnal home haemodialysis (NHHD), is often the main type of therapy in home haemodialysis (HHD). 2. As a rule, patients living far from the hospital cannulate themselves and are therefore principally responsible for their access survival. 3. As a consequence, the buttonhole (BH) technique is popular amongst patients on HHD. HIGH DOSE DIALYSIS Whereas in hospital thrice weekly short dialysis is often the rule, one of the greatest benefits of HHD is the possibility for more frequent and longer dialysis. The papers reporting the multiple benefits of frequent HD on morbidity, mortality and quality of life are numerous, and include Williams et al. (2003), Kooistra (2003) and Twardowski and Misra (2010). 28 Journal of Renal Care European Dialysis and Transplant Nurses Association/European Renal Care Association

2 SUCCESSFUL VASCULAR ACCESS MANAGEMENT FOR HOME HAEMODIALYSIS: A PRACTICAL APPROACH However, concern exists about its effects on access survival. One would expect that twice as many punctures and the extra exposure of the fistula to high blood flows would increase the risk of malfunctioning. Nevertheless, when reviewing the literature, the effects are hard to verify, due to local variations in blood flow, number of cannulations and cannulation technique. However, there is no consensus about the blood flow required and in a number of NHHD studies a lower blood flow is applied. But, new developments are entering the dialysis market, like the NxStage R (Lawrence, KS, USA) SDHD treatment. The NxStage requires, at present, two needles and high blood flows. Most centres double the number of punctures when increasing from three to six dialyses a week for HHD. Therefore, some centres offer their patients on NHHD and even SDHD single needle dialysis, with excellent results (Kooistra 2003; Leitch et al. 2003; Lindsay et al. 2003). Our unit compared conventional dialysis with two-needle dialysis (three to four hours thrice weekly) with six sessions a week on single needle dialysis (mean blood flow 200 ml/min, sessions of two hours). Results showed that Kt/V remained stable and haemodynamic control and quality of life improved (Kooistra et al. 1998). In studies on frequent dialysis, the BH method was preferred over the usual rope-ladder technique. However, results must be viewed with caution due to patient selection, as patients on SDHD and NHHD tend to be younger, are more motivated and have fewer co-morbidities. A review of the literature reveals that failure rates and fistula survival are not necessarily unfavourable in high dose dialysis, despite the fact that in most studies patients cannulate their fistula with two needles and maintain a high blood flow regime. In a number of studies that evaluated high dose dialysis, failure of vascular access was not reported as a significant problem (Quintaliani et al. 2000; Kjellstrand et al. 2003; Lindsay et al. 2003; Williams et al. 2003; Piccoli et al. 2004; Castro et al. 2006; Punal et al. 2008; Rodenberger 2011). One of the explanations could be that frequent dialysis is associated with fewer intra-dialytic hypotensive episodes, which are often detrimental to vascular access (Twardowski 2004). However, two North American studies did report increased vascular access problems. Both studies maintained a two-needle regime during frequent dialysis. Some patients and staff have reported problems due to the large number of punctures (Goldfarb-Rumyantzev et al. 2006). In a relatively large randomised trial, with 125 patients on frequent dialysis and 120 patients on thrice weekly dialysis, the authors reported more interventions in the first group (95 compared with 76 interventions), but there was no statistical difference in access failure. Both groups were treated with double needle dialysis and high blood flow rates of 400 ml/min (The FHN Trial Group 2010). Quintaliani et al. (2000) found a protective role for men with regard to access failure. This is an observation that every experienced nurse will confirm. Male blood vessels are bigger and longer, easier to cannulate and will then probably cause less complications. When a patient with a fragile AV fistula changes to high dose dialysis, one should consider a single needle dialysis technique. In our experience, when we failed to reach a sufficient Kt/V in a patient of 145 kg on single needle dialysis, BH cannulation was the solution. Finally, in cases of high dose dialysis using a central venous catheter, two studies reported superior catheter survival compared with conventional HD (Lindsay et al. 2003; Perl et al. 2006). This might be explained by an effect of short intradialytic periods, which can mean less time for colonisation of micro-organisms or for clotting of the catheter. Moreover, high dose dialysis requires lower blood flows than conventional dialysis, so minor clotting episodes may not result in alarming arterial or venous pressures on the dialysis machine. In summary, high dose dialysis can sometimes be a risk factor for vascular access problems or even failure. Furthermore, one would expect that lower blood flow and a single needle dialysis technique should minimalise the supposed negative effects of high dose dialysis on access survival. Single needle dialysis not only reduces the number of punctures by half but also lengthens the available cannulation area. Overall results on single needle SDHD in our centre (Kooistra et al. 1998) and single needle, low blood flow NHHD have been found to be excellent (Kooistra 2003). SELF-CANNULATION As a rule, the patient who chooses HHD is obliged to perform self-cannulation. Self-cannulation has a number of advantages: 1. Self-management: patients take ownership of their care and control of their lives. They lose fear of dialysis, of pain and of 2013 European Dialysis and Transplant Nurses Association/European Renal Care Association Journal of Renal Care

3 Verhallen access problems, because they are empowered and are no longer dependent (Mott 2011). 2. People who self-cannulate are able to feel the needle inside their vessel during the procedure of cannulation, so they know how their vessel feels and they will quickly notice developing problems. 3. The patient does not have to worry anymore about the cannulation process on holidays, because he/she will continue cannulating himself. However, not everyone who self-cannulates is confident in their ability and needle phobia can be a big issue. A Canadian study revealed that needle phobia kept 47% of their patients from self-care (McLaughlin et al. 2003).However,if guided well, many patients will overcome this barrier. Once the big step of the first self-cannulation is taken, patients are likely to never hand over the needle to a nurse anymore. However, some patients will never become self-confident cannulators. This group will need continued professional support and guidance. As the traditional advice is to rotate accesssitesasmuchaspossibleinordertoallowtheskinto heal (the rope-ladder technique), this in turn can increase anxiety as rotation of sites can enhance the risk of cannulation failure. Nurses often have different priorities when cannulating fistulae or grafts. Hospital staff are focused on prevention of long-term complications, whereas self-cannulators are more focused on a tranquil dialysis with a painless, purposeful and fast cannulation. The latter is in contradiction to the traditional rope-ladder technique. Fearful patients (and nurses alike) will be tempted to use the so-called area puncture technique. This is repeated cannulation in a small area, which may cause damage to the skin and the vessel wall, producing aneurysmal dilatations of the puncture areas (Krönung 1984). The solution seems obvious in recent years, the BH method has gained popularity amongst patients on HHD and also with professionals (Peterson 2002). THE BH TECHNIQUE Using the BH method, cannulation takes place at exactly the same spot at consecutive dialysis sessions, thus developing a tunnel track to the AV fistula (Krönung 1984). A BH which is used daily tends to grow sore. So in general a patient needs two BHs. This will be sufficient for double needle dialysis up to four times a week or for daily single needle dialysis. From the patient s point of view, the BH method is far less stressful and therefore is often the cannulation method of choice (Leitch et al. 2003). The procedure is less painful, faster and easier. It does not lead to difficult choices prior to each dialysis to determine the cannulation spot. There is less haematoma formation and a shorter haemostasis time postdialysis (Leitch et al. 2003; Verhallen et al. 2007). There is also the advantage of less visible scar tissue. In two long-term trials, the medical benefits of the BH method have been clearly established. When damage has already been done, BH cannulation allows the healing of damaged skin and might stop the growth of aneurysmic dilatations. This is an important factor in survival of problematic fistulae (Marticorena et al. 2006). In a trial consisting of 145 patients, with a followup of nine months, Van Loon et al. (2009) describe a significant lower number of angioplasties in the BH group, compared with the rope-ladder group. However, many professionals have their doubts about this BH procedure and cite the higher risk of infections with potential life-threatening complications, like bacteraemia, septic arthritis, pericarditis, and the risk of uncontrollable fistula bleeding. In contrast, the pioneers of BH technique in the last century reported hardly any serious adverse events of the BH method (Twardowski & Kubara 1979). However, the increased popularity of upper arm AV fistulae with its short and tortuous tracks, the ageing population of patients on HD, the high prevalence of vascular co-morbidities and in addition the rise of high dose HHD, all increased interest in the BH method. To perform the rope-ladder technique correctly, a cannulation area of more than 10 cm is needed in order to be able to rotate the needle sites and keep sufficient distance in between (Van Loon et al. 2009). This is not necessary for the BH method, in which a fistula length of 2 cm can be sufficient to achieve an efficient dialysis. However, evidence shows that there can be a higher risk of infections (Marticorena et al. 2006; Verhallen et al. 2007; Doss et al. 2008; Van Loon et al. 2009; Birchenough et al. 2010). It seems obvious that the tunnel tracks may host micro-organisms and require more meticulous cleaning than the usual disinfection procedure, so this makes the BH technique inappropriate to apply to grafts. Different reports describe that the use of blunt needles, intensified antiseptic protocols and thorough education of the staff on antiseptic techniques, can reduce the infection rate (Marticorena et al. 2006; Birchenough 30 Journal of Renal Care European Dialysis and Transplant Nurses Association/European Renal Care Association

4 SUCCESSFUL VASCULAR ACCESS MANAGEMENT FOR HOME HAEMODIALYSIS: A PRACTICAL APPROACH et al. 2010). Very recently Laird (2012) reported remarkable results from using exfoliating facial buffs in combination with antibacterial soap to clean the BH sites. Since 2010, 4,000 BH cannulations have been undertaken with zero infection. The main challenge for the survival of the BH method is prevention of Staphlococcus aureus infections. Patients on dialysis in general are particularly vulnerable to infections caused by this micro-organism, which accounts for more than 8% of the mortality in the dialysis population and is the leading cause of mainly access-site-related infections (Vandecasteele et al. 2009). In general, AV fistulae are the most popular type of vascular access (FistulaFirst 2012). This applies even more so in HHD, considering the fact that in general patients at home have less co-morbidity and suffer less vascular complications. In general, the incidence of bacteraemia due to infected fistulae is relatively low (Schild et al. 2008; Son et al. 2010). However, several factors associated with BH cannulation may increase the risk of infection: errors in the cannulation technique, skin and tunnel colonisation, loss of skin integrity at the access site and frequency of cannulation. HOW TO SUSTAIN A LONG LASTING ACCESS FOR PATIENTS UNDERGOING HHD Some general advice based on reviews and our own experience in our HHD unit (135 patients) is as follows: 1. Convince the patients that they have to wash the puncture site just before cannulation. The majority of S. aureus infections in patients should be regarded as auto-infections (Kaplovitch et al. 1988; Arduino & Tokars 2005; Vandecasteele et al. 2009). Kaplovitch et al. (1988) found that patients with poor hygiene had a significantly higher concentration of S. aureus on the skin near the vascular access, even after application of antiseptic. Therefore, excellent personal hygiene is the most important factor in prevention of this kind of infection. Frequent reinforcement of aseptic technique is crucial to avoid errors and prevent accessrelated infections (Doss et al. 2008). 2. Teach the patient what he/she can do to recognise access problems. Patients can learn how to use the stethoscope daily and how to recognise unfavourable changes. Patients can be taught the importance of changes in venous and arterial pressure and how to select the best cannulation spots. 3. Develop re-training programmes for hands-on training at home. One of the benefits of self-cannulation is that the same person, the patient himself, observes and feels the access very frequently and will acutely notice sudden unfavourable changes. A well-trained, self-conscious patient will ask for advanced access care before the regular visit of a dialysis professional or flow measurement. 4. Organise regular observations of the access and the needling procedure in the home environment, as the patient on HHD although self-caring lacks the clinical experience and medical background of a healthcare professional and might fail to recognise unfavourable changes in his access in the long term. SPECIFIC INSTRUCTIONS FOR GOOD FISTULA CARE Specific instructions for good fistula care include: 1. How to disinfect the skin and how to hygienically remove BH scabs. 2. How to avoid making unnecessarily long BH tunnels, as sometimes, when BHs are cannulated with sharp needles, the BH wanders off. Rather than abandoning the BH, the patient then proceeds with cannulating in an awkward oblique angle, creating a longer tunnel. It is therefore important to convince the patient to abandon that site and find a new one. 3. How to reduce damaging the opposite side of the vessel wall. Patients should puncture the vessel at a 258 angle and, when blood flashback becomes visible lower the needle to proceed. Some patients show a tendency to move downwards too long and thus damage the opposed vessel wall. 4. How to avoid digging false tracks alongside the fistula. The use of blunt needles in combination with inadequate cannulation skills may prompt a patient to use excessive force, thus creating false tracks. Special attention must be paid to this when training. 5. Selecting the correct needle. Attention must be paid to: The length of the needle: in only a very small number of fistulae is it necessary to use steel needles longer than 20 mm. Longer needles are more difficult to handle when self-cannulating and they are more intimidating and will unnecessarily add to the risk of wall damage (Mott 2011). If an experienced patient insists on longer needles, he may cannulate too shallowly, or, in case of BH technique, the position of the BH in relation to the access wall might have shifted to the side. The use of sharp or blunt needles: The use of blunt needles is recommended. Blunt needles are rounded on the top 2013 European Dialysis and Transplant Nurses Association/European Renal Care Association Journal of Renal Care

5 Verhallen Soften the scabs to facilitate easy removal. Different softeners are described in the literature, amongst others, a warm wet towel or a gauze with alcohol containing gel. Softening with an ointment based on a fatty substance works best: e.g. chlorhexidine ointment, applied half-an-hour before the procedure. Also Emla 1 (AstraZeneca, Wilmington, DE, USA) is a painkilling cream with 2.5% lidocaine which can also soften the buttonhole scab. Those patients who still feel a sharp pain during buttonhole cannulation report that the use of pain killing cream benefits the cannulating procedure. Clean the buttonhole sites with an antibacterial agent prior to scab removal following the manufacturer s recommendations. Remove the scabs completely. Care must be taken not to traumatise the exit site to prevent auto-infections. Use a blunt object: for instance, a sterile blunt fill needle (BD, Franklin Lakes, NJ, USA), tweezers, or a pick that comes the Nipro biohole Needle 1 (Nipro Medical Corp., Miami, FL, USA) to remove the scab. Be aware that a sterile object is not sterile anymore from the moment the scab is touched so prevent digging around the exit site. Wear surgical masks, as is common practice when handling central venous catheters as KDIGO (2009) recommends. As the majority of patients, and nearly all assistants at home, including nurses, are never checked for the presence of S. aureus in their nose, wearing a mask may prevent possible cross-infection. Make sure that the arm always lies in the same position, and the exit site is right above the fistula. The same goes for fixation of the skin (if used). Prevent hubbing (Ball & Mott 2010) which is where repeatedly pushing the needle hub against the exit site, the hub will leave a cave-like indented buttonhole site. This makes it very difficult to remove the scab completely. Finally do not overuse a buttonhole. In many patients, buttonholes get sore, swollen and red, if used two days in a row. Table 1: Advice to be given to patients prior to cannulation. After haemostasis, place an antibacterial ointment on the exit site and cover the buttonhole with a sterile gauze or plaster for at least six hours. Since dialysis can take several hours S. aureus returns to the skin during dialysis and incorporates into the scabs after needle removal. The application of a local antibacterial ointment has proved to be successful in reduction of exit site infections (Vandecasteele et al. 2009). Nesrallah et al. (2010) had good results applying Mupirocin calcium 2% cream (Bactroban 1, Glaxo-Smith-Kline, Brentford, UK) to the buttonhole. Marticorena et al. (2006) have experience with applied betadine or polysporin 1 (Johnson & Johnson, Markham, ONT, Canada, USA) and reported that few infectious complications were seen. Also be aware for the infrequent occurrence of mupirocin resistant Staphylococcus (Rossney & O Connell 2008). Table 2: Advice to be given to patients post-cannulation. and do not have a sharp, cutting edge like traditional dialysis needles. Since access is entered through a specially formed track, there is no need for sharp needles (FistulaFirst 2012). However, Searching for the tunnel with blunt needles can cause a niche for bacteria or create multiple tunnels. Once a BH is formed, it is important to never switch back to sharp needles without proper reason. Track formation, which requires variable time and depends on the local condition of the skin and vessel wall and the ability of the patient (Castro et al. 2010). When the needle slides in the vessel without effort, the tunnel is ready for cannulation with a blunt needle. However, some patients will never be able to use blunt needles. It is important to advise against excessive force when using blunt needles, as this could possibly tear tissue (Ball 2006). The use of a catheter needle in specific situations. Cannulating a catheter needle is a complex operation and is required more and more in tortuous upper-arm fistulae. In practice, most patients can learn to cannulate using a catheter needle, even single-handedly. 6. Continuous monitoring of access flows and dialysis pressures is crucial to identify access problems at an early stage (Leitch et al. 2003). CANNULATING BUTTONHOLES IN A SAFE WAY Advice can be given to patients in order to facilitate safe cannulation. See Tables 1 and 2 for prior to cannulation and post-cannulation, respectively. Finally, it is crucial to train the staff. Repeated and intensive education needs to be conducted yearly or more frequently if changes are made to policy and procedure (Birchenough et al. 2010; Labriola et al. 2011). CONCLUSION HHD and its potential for high dose dialysis is a topical issue worldwide. There is, however, concern about its adverse effects on access survival. Furthermore, for many patients, self- 32 Journal of Renal Care European Dialysis and Transplant Nurses Association/European Renal Care Association

6 SUCCESSFUL VASCULAR ACCESS MANAGEMENT FOR HOME HAEMODIALYSIS: A PRACTICAL APPROACH cannulation is often the largest challenge. Both problems might be resolved by applying a single needle dialysis technique or using the BH method, although there is the elevated risk of infection. It is of the utmost importance that in order to apply the BH method safely, staff and patients alike must follow protocols painstakingly. Continued training and re-training of staff and patients will be vital to gain and maintain a wide understanding of the potential risk factors and to convince them of the importance of the strategies to reduce the incidence of infection. ACKNOWLEDGEMENTS P. Vos and R. Hené gave advice and helped amend the original version of the manuscript. CONFLICT OF INTEREST No conflict of interest has been declared by the author. AUTHOR CONTRIBUTIONS AV undertook the literature review and wrote the manuscript. REFERENCES Arduino M.J. & Tokars J.I. (2005). 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