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1
Subcutaneous anastomosis (communications)
of an artery to a vein, allowing blood flow
directly moves from artery to vein
A...
3
 AVF is a continuous circuit (not only anastomosis)
 Starts at the heart and ends at the heart
 The circuit:
 Usually ...
Advantages of AVF
Lower risk of infection
Lower tendency to clot fewer 2ry interventions
Lower hospitalization rates (...
Disadvantages of AVF
1. Slow maturation and failure of maturation
2. More difficult to needle.
3. Increase in size with ag...
Vascular anatomy of upper limb
• Basilic vein: drain medial side of upper limb
• Cephalic vein: drain lateral side of uppe...
Types of common arteriovenous fistula
according to method of anastomosis:
8
Types of common arteriovenous fistula
according to its site in the upper limb
Forearm
AVF
Radial artery to cephalic vein
R...
1.Radial–cephalic AV fistula ( wrist )
10
2.Brachial–cephalic AV fistula (elbow)
11
3.A transposed brachial basilic vein fistula
12
13
•Pre-operative care in hand for AVF
This begins as soon as finish vascular assessment
and site for access was decided.
D...
Post-Operative care of AVF or AVGs
Immediately following surgery (half-hourly at first),
the site of AVF should be checked...
 Assess the access patency: palpate (thrill) or listen
(bruit)
 Monitor BP and hydration status, to prevent access
clott...
Patient Education (Daily Care)
Good fistula care will help maintain the patency of
the vascular access.
Education is the...
 Avoid check BP, venipuncture or IV drugs ,
sleeping on the access arm
 Use the access site only for dialysis
 Wash the...
19
Cannulation is one of the 1ry causes of AVF failure
Sequences of needle punctures into the vessel wall
 Endothelial inj...
Personal protective devices
(Standard Precautions)
Strict hand washing
Eye protection (face shield or goggles)
Mask
Gl...
Rapid examination AVF
• LOOK
• FEEL
• LITEN
22
Fistula maturation
Rule of 6's
6 weeks old
6 mm deep
6 mm fistula diameter
600mL per min flow 23
Skin Preparation
Patients should wash their hands with anti-bacterial
soap and water before dialysis scission
Clean the ...
25
Local Anesthetic
Use of topical anaesthesia (lidocaine
cream) on site of cannulation at least
half an hour prior to cannul...
Needle types
Two main types
1.Metal needle 2.Plastic needle
27
Metal needle 28
Plastic needle 29
General rules for cannulation
The initial cannulation will be a sharp metal needle
(metal needles are either sharp or blu...
 Sharp needles, used for the rope ladder
technique, have a sharp cutting edge.
 Blunt needles, designed for the buttonho...
Needle length
1. Metal needles are range from 2.5cm to1.5cm
(which is for shallow new fistula).
2. Plastic cannula needle...
Metal needle Plastic needle
• Cannulation is easy
• Miscannulations is low
• Low cost
• Severe vessel injury
• Higher risk...
Needle site selection (Placement of needles)
4-5 cm (1.5-2 inches) apart, hub to hub, if
needles in the same direction
2...
35
 Venous needle pointing in the direction of the
blood flow
 Arterial needle pointing toward the arterial
anastomosis.
 ...
37
38
Needle size selection
17 gauge needle for first attempts and for one
week with two needle cannulation without
complicatio...
 During choice the needle size , Must follow the
2:1 rule- arterial and venous pressure should not
exceed 50% of the pump...
Back eye
The arterial needle should always have a back-eye
 It should be smooth and flat so that its rim does not
cut int...
42
Bevel position/ flipping of needle
Angle of insertion is 20-35 degree (depending on
vein depth)
The retrograde direction...
 Avoid flipping (rotating)the needle as this will
cause coring of the vessel
 If flipping is essential as in case of inc...
 Better use the ultrasound to determine optimal
cannulation sites and assess needle position,
before re-positioning the f...
Number of attempts
 Better to use the portable ultrasound if available
for assessment of needle position and vein
depth/d...
 If doubt that needle has infiltrated, remove the
needle to decrease vessel damage and apply ice
 If patient has receive...
Securing of needles
Needles should be secured at the same angle of
insertion to avoid change in needle position and
minim...
Needle Removal and Hemostasis
Needles should be removed at the same angle of
insertion
Do not apply pressure while the n...
 Dispose of the needle ( follow Occupational Health
standards)
 Make press at least for 10 min without releasing
pressur...
Troubleshooting Needle Placement and
increased venous and/ or arterial pressures.
Decrease blood pump speed
Measure bloo...
 Carefully reposition access limb
 Use portable ultrasound to check position of
needle prior to re-positioning or adjust...
 If unsuccessful, recirculate patient’s blood and
recheck needle position with portable ultrasound If
repositioning is un...
Complicationsof Cannulation of Needle
2.During HD
1.During cannulation 3.On needle removal
54
During cannulation (extravasation)
Needling an AVF which is too small, not mature
enough, or very mobile can easily lead ...
 Extravasation is treated by applying pressure, ice, and
administering analgesia.
 Blown arterial needle with satisfacto...
57
Problems during HD
Needle dislodgement
Can be identified by pressure alarms on the
machine, bleeding from needle entr...
58
Suckling up of needle against the
vessels wall
Reduced arterial pressure and mild
pain or vibration at the arterial n...
59
Needles fall out during HD
Result from poorly secured needle sites
or excessive patient movement.
Pressure on needle...
60
Problems following dialysis ( on needle removal)
Delayed haemostasis
Most common complication following HD
Not turnin...
61
Cannulation Techniques
Site-Rotation Buttonhole
Known as:
1.Rope ladder
2.Rotating sites
Known as:
1.Constant-site
2.Sa...
62
Rope ladder ( Site- Rotation technique):
Cannulation sites are rotated up and down the
AVF to use its entire length wi...
63
No need to ‘straighten out’ by pulling on the
vessel to cannulates, the vessel will retract
into its original position...
64
Advantage:
lower rate of infection
Help expand the lifespan of the fistula.
Changing cannulation site gives the prev...
65
66
67
68
“ONE-SITE–ITIS”
Occurs when cannulates the needle in the same
general area, session after session
Causes aneurysm and...
69
Buttonhole Technique
Method in which an individual cannulates the AV
fistula in the exact same spot, at the same angle...
70
 After the buttonhole is created, a blunt dialysis needle
should be used, which eliminates the risks of cuts and
bleed...
71
ADVANTAGES
May prolong AVF lifespan
Reduce needling attempts
Reduces pain
Reduces bleeding and hematoma
Reduces in...
72
DISADVANTAGES
Requires same cannulator, same angle, same
location
High rate of infection
Concerns of ‘one-site-its’
...
73
Indications of buttonhole
technique:
Indication to use rope ladder
technique
• AVF is short in length
or has short usab...
74
Indications of buttonhole
technique:
Indication to use rope
ladder technique
• AVF is difficult to
cannulates (self
can...
75
Complications of fistula
76
1-Aneurysm , Pseudo aneurysm
A consequence of an AV fistula creation is
thickening and enlargement of the vein walls d...
77
 This aneurysm is secondary to repetitive
cannulation in the same area (same=site itis)
which lead to weakness of vess...
78
 Aneurysm and pseudo aneurysm may also be
caused by a proximal stenosis.
 Patients with aneurysms may present to the
...
79
 Diagnosis
 Both AV fistula aneurysm and pseudoaneurysms
can be identified with the use of Doppler US.
80
 Management:
 Changing needle sites and vascular surgery
for operative repair.
 Surgery is indicated when the aneury...
81
2-Infection:
AV fistulas have lowest risk of infection of any
vascular access type.
Pre- cannulation must checking si...
82
Causes
Inadequate disinfection of the skin
Contamination of the needle
Manipulation of the needle during dialysis
...
83
84
 Management:
 Must be managed urgently as it can lead to
thrombosis or sepsis if left untreated.
 Do not cannulates
...
85
 Prevention:
1. Pre and post treatment washing of access
2. No scratch on the access site
3. Appropriate skin antiseps...
86
3-Thrombosis (clotting)
The most common complications of AVF.
Venous stenosis resulting in reduced blood flow,
infect...
87
 Causes
 Surgical/technical problems
 Preexisting anatomic lesions
 Premature use
 Poor blood flow or hypotension
...
88
Clinical
 Absence of pulse/thrill on palpation ( feel firm)
 Absence of bruit on auscultation
 No blood or blood cl...
89
Management ( Urgent treatment is required to
prevent the failure of the access)
 Do not needle
 Take blood sample to...
90
4-Bleeding
Causes
Bleeding after remove needle
Anticoagulation/not stopping prior to end of HD
Improper pressure wi...
91
Symptoms and signs
Needle sites bleed >10mins following HD
92
Management:
 Stop anticoagulation 1hr prior to the end of HD
 Apply directed pressure
 Consider coagulants (Protami...
93
5-Infiltration = Hematoma
The pathological accumulations of substances in
tissue or cells which are normally are absen...
94
 How to prevent the infiltration:
During cannulation
 Don’t flip needle
 Don’t lift needle in vein
 Check for flash...
95
Post hemodialysis
Apply gauze without pressure during
removal of needle
Remove needle at insertion angle
Apply pres...
96
Management of infiltration:
 Elevate arm above heart
 Ice 20 minutes on/20 minutes off for 24 hours
 Warm compresse...
97
Hematoma
 If bruising or hematoma occurs after dialysis, the
surface skin site has sealed but the needle hole in
the ...
98
6-Poor arterial flow and increased venous
pressure
May be due to location or position of needle
May be there are thro...
99
 Management:
 An angiogram or Doppler US should be performed to
detect stenosis or thrombosis.
 Recirculation tests ...
100
7-Stenosis:
Most common complication
Hyperplasia in lumen (usually arterial side)
Frequent cause of fistula failure...
101
 Type of stenosis:
1-Juxta-anastomotic (most common stenosis in AVF)
2-Mid-access stenosis
3-Outflow stenosis
4-Centr...
102
Clinical key that there is stenosis:
 Clotting of the extracorporeal circuit 2 or more
times/month
 Persistently sw...
103
 Inability to achieve optimum blood flow rate.
 Changes in Kt/V and URR
 Recirculation
 Prolonged postdialysis ble...
104
 Diagnosis
 Physical examination and/or flow measurement
should be performed as soon as possible.
 Duplex scan/fist...
105
Parameter Normal Stenosis
Thrill Only at the arterial
anastamosis
At site of stenotic
lesion
Pulse Soft, easily
compre...
106
Management
Call surgical team for corrective treatment:
Percutaneous trans-luminal angioplasty is the first
treatment...
107
 Steal syndrome: Deprivation of blood distal to
AVF/AVG
Steal syndrome (ischemia of the hand)
 Inadequate blood sup...
108
Risk factors
 Brachial arterial origin
 Diabetes mellitus
 Peripheral vascular disease (PVD)
 Female gender
109
 Clinical picture:
 Most patients are asymptomatic
 Cold sensation and pale colour of the fingers
 Ischemic pain
...
110
111
Diagnosis of Steal Syndrome
Clinical investigation –Allen test.
Noninvasive imaging tests: measurement of
digital p...
112
Allen test.
 A medical sign used in physical examination of
arterial blood flow to the hands.
 The hand is normally...
113
 These two arteries connect to form an anastomosis,
so if one of the arteries becomes compressed or
occluded, the blo...
114
 While the patient opens and closes his hand, release
one of the arteries, evaluating how fast refill occurs
to the h...
115
116
Management of Steal Syndrome
 Early referral to the surgical for revision of access
 the DRIL distal revascularizat...
117
Examination of the mature
hemodialysis arteriovenous fistula
Examination of the mature
hemodialysis arteriovenous fist...
118
 Routine physical examination of the fistula lead to
early detection and treatment of any problems
 The 2006 Nationa...
119
 Examination must be done every hemodialysis
treatment.
 Must be known by all clinical staff who dealing
with fistul...
120
 Inspection
 Position of the fistula
1. Radiocephallic
2. Brachiocephallic
3. Transposed cephallic
 Presence of oth...
121
 Expose the entire extremity with the AV access
 Compare any change in the limb to the non-access
limb
 Signs of in...
122
 Outflow stenosis (Arm Elevation Test): When the
access arm is elevated to a level above the heart.
o The absence of ...
123
124
 Access-induced ischemia or steal syndrome (signs
of cyanosis of the finger tips and delayed capillary
refill of the ...
125
 Appropriateness of vessel size (depth and diameter)
for cannulation suitability
 Location for previous cannulation ...
126
 Palpation for AV fistula
 Evaluate for possible cannulation sites =
superficial, straight vein section with adequat...
127
 Pulse
o Normal AVF is soft, compressible and non-
pulsatile
o A pulsatile fistula is suggestive of obstruction or
st...
128
129
 Temperature Change
 Feel the access skin temperature
o Warmth = possible infection
o Cold = decreased blood supply
...
130
 The thrill must be assessed by palpating the entire
length of the AV fistula to determine access patency
(The vein s...
131
 A strong thrill should be palpable at the arterial
anastomosis diminishing distally, closer to the venous
end.
 Cha...
132
 Occasionally, a thrill can be palpated in the axillary
or subclavian region, particularly in thin chested
individual...
133
 Pulse augmentation test ( for inflow stenosis)
 The normal AV access is soft and compressible but
non-pulsatile.
 ...
134
 If the pulse augmentation is poor ( weak or absent
pulse with obstruction )  poor arterial inflow
135
Auscultation
 Listen for Bruit
 Begin at the AV anastomosis and continue along the
length of the access noting any ...
136
 An obstructed (stenotic) fistula may have a
discontinuous and pulse-like bruit rather than a
continuous one and also...
137
138
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Fistula (Arteriovenous fistula -AVF)

Arteriovenous fistula (AVF)
all what u want to know about fistula

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Fistula (Arteriovenous fistula -AVF)

  1. 1. 1
  2. 2. Subcutaneous anastomosis (communications) of an artery to a vein, allowing blood flow directly moves from artery to vein Arteriovenous fistula (AVF) 2
  3. 3. 3
  4. 4.  AVF is a continuous circuit (not only anastomosis)  Starts at the heart and ends at the heart  The circuit:  Usually the anastomosis is made at the wrist between the radial artery and the cephalic vein 4
  5. 5. Advantages of AVF Lower risk of infection Lower tendency to clot fewer 2ry interventions Lower hospitalization rates (lower complication rates ,lower morbidity and mortality) Allows for greater blood flow Long-term patency (improved performance with time) Less cost of implantation and maintenance. 5
  6. 6. Disadvantages of AVF 1. Slow maturation and failure of maturation 2. More difficult to needle. 3. Increase in size with age and aneurysm formation. 4. Cosmetic appearance of dilated veins. 6
  7. 7. Vascular anatomy of upper limb • Basilic vein: drain medial side of upper limb • Cephalic vein: drain lateral side of upper limb 7
  8. 8. Types of common arteriovenous fistula according to method of anastomosis: 8
  9. 9. Types of common arteriovenous fistula according to its site in the upper limb Forearm AVF Radial artery to cephalic vein Radial artery to basilic vein Radial artery to any other transposition Arm AVF Brachial artery to cephalic vein Brachial artery to basilic vein Brachial artery to any other 9
  10. 10. 1.Radial–cephalic AV fistula ( wrist ) 10
  11. 11. 2.Brachial–cephalic AV fistula (elbow) 11
  12. 12. 3.A transposed brachial basilic vein fistula 12
  13. 13. 13
  14. 14. •Pre-operative care in hand for AVF This begins as soon as finish vascular assessment and site for access was decided. Don’t insert peripheral IV catheters or cardiac pacemaker Don’t use for blood draws or IV drugs Don’t use for taking blood pressure or try any surgical procedures 14
  15. 15. Post-Operative care of AVF or AVGs Immediately following surgery (half-hourly at first), the site of AVF should be checked for : Excessive bleeding, haematoma, swelling, pain and later signs of infection such as raised temperature. Check radial pulse, colour, movement, warmth, and sensitivity of affected limb to ensure blood flow reaches extremities (peripheral circulation). 15
  16. 16.  Assess the access patency: palpate (thrill) or listen (bruit)  Monitor BP and hydration status, to prevent access clotting.  Elevate the access arm to help minimize oedema and swelling.  Assess patient for pain  Report any abnormality to medical team ASAP. 16
  17. 17. Patient Education (Daily Care) Good fistula care will help maintain the patency of the vascular access. Education is the responsibility of the nurse: •Check the thrill at least once daily •Avoid tight clothing , jewellery or watch •Avoid carrying heavy object •Avoid exposure to extremes of heat/cold 17
  18. 18.  Avoid check BP, venipuncture or IV drugs , sleeping on the access arm  Use the access site only for dialysis  Wash the access with soap and water pre-dialysis  Signs of infection (pain, swelling, redness…….)  Absence of thrill must be reported to the renal unit.  (The fistula may need 6–8 weeks to mature and ideally ≥12 weeks. ) 18
  19. 19. 19
  20. 20. Cannulation is one of the 1ry causes of AVF failure Sequences of needle punctures into the vessel wall  Endothelial injury  leukocyte adhesion migration of smooth muscle cells from the media to the intima and proliferation.  Intimal hyperplasia  thickening of the vessel wall venous stenosis (main cause of access failure).  Infiltration, aneurysms and hematoma  needle- induced vessel injury 20
  21. 21. Personal protective devices (Standard Precautions) Strict hand washing Eye protection (face shield or goggles) Mask Gloves (Use according to unit standards to ensure staff protection) 21
  22. 22. Rapid examination AVF • LOOK • FEEL • LITEN 22
  23. 23. Fistula maturation Rule of 6's 6 weeks old 6 mm deep 6 mm fistula diameter 600mL per min flow 23
  24. 24. Skin Preparation Patients should wash their hands with anti-bacterial soap and water before dialysis scission Clean the skin using 2% Chlorhexidine gluconate solution with alcohol (drying time 30 seconds), Povidine-iodine (drying time 2–3 min), using friction and a circular motion Leave the solution to dry, prior to needle insertion Do not touch skin after cleaning (If touch, re-clean)24
  25. 25. 25
  26. 26. Local Anesthetic Use of topical anaesthesia (lidocaine cream) on site of cannulation at least half an hour prior to cannulation. 26
  27. 27. Needle types Two main types 1.Metal needle 2.Plastic needle 27
  28. 28. Metal needle 28
  29. 29. Plastic needle 29
  30. 30. General rules for cannulation The initial cannulation will be a sharp metal needle (metal needles are either sharp or blunt bevel). To begin rope ladder/rotating site technique Same-site cannulation in order to establish tunnel tracks for the buttonhole technique. Plastic cannulas can be left in the vessel for a period of time to develop the buttonhole tunnel track. 30
  31. 31.  Sharp needles, used for the rope ladder technique, have a sharp cutting edge.  Blunt needles, designed for the buttonhole technique, are rounded on top (no sharp edge)  Black and red dots indicate the position of the needle even during the treatment ( to know if flipping happen after insertion of needle ).  Wing colour indicates needle diameter 31
  32. 32. Needle length 1. Metal needles are range from 2.5cm to1.5cm (which is for shallow new fistula). 2. Plastic cannula needles can be up to 3.8 cm (which is for deep AVF) 32
  33. 33. Metal needle Plastic needle • Cannulation is easy • Miscannulations is low • Low cost • Severe vessel injury • Higher risk of needle infiltration during taping or mid-treatment • Limited areas for Cannulation • Less comfortable for patients’ arm movements during the dialysis • Not suitable for deep AVF cannulation . Difficult . High . Higher . Less . Low . Increased . Comfortable . Suitable 33
  34. 34. Needle site selection (Placement of needles) 4-5 cm (1.5-2 inches) apart, hub to hub, if needles in the same direction 2.5 cm (1 inch) apart, hub to hub ,if needles in opposite direction Insertion site or needle tip once inserted, 4 cm (1.5 inches) away from the anastomosis 34
  35. 35. 35
  36. 36.  Venous needle pointing in the direction of the blood flow  Arterial needle pointing toward the arterial anastomosis.  Venous needle must point toward the venous return and arterial needle, may point in any direction.  May use ultrasound mapping for depth and size. 36
  37. 37. 37
  38. 38. 38
  39. 39. Needle size selection 17 gauge needle for first attempts and for one week with two needle cannulation without complication Increase needle gauge till 15 gauge needles 39
  40. 40.  During choice the needle size , Must follow the 2:1 rule- arterial and venous pressure should not exceed 50% of the pump speed e.g., 400 ml/min blood pump speed, arterial and venous pressure should be -200/200 mm/hg respectively  Arterial and venous pressure should not exceed -250 or 250 mm/hg to avoid damage to the access 40
  41. 41. Back eye The arterial needle should always have a back-eye  It should be smooth and flat so that its rim does not cut into the vessel during needle insertion or withdrawal. Maximize flow from the access. Prevents suction of the needle to the inner vessel wall and reduces the need for rotating the needle, which adds trauma to the AVF. 41
  42. 42. 42
  43. 43. Bevel position/ flipping of needle Angle of insertion is 20-35 degree (depending on vein depth) The retrograde direction of the arterial needle and bevel down cannulation increase possibility of access failure The antegrade direction of the arterial needle with bevel up cannulation may improve access survival 43
  44. 44.  Avoid flipping (rotating)the needle as this will cause coring of the vessel  If flipping is essential as in case of increased needle pressures, must be done carefully to avoid damage to access (if fistula needles with a back- eye the need to flipping the needle is decreased)44
  45. 45.  Better use the ultrasound to determine optimal cannulation sites and assess needle position, before re-positioning the fistula needle 45
  46. 46. Number of attempts  Better to use the portable ultrasound if available for assessment of needle position and vein depth/diameter If cannulation is failed or infiltration occurs, call cannulator or clinical educator Don’t push saline or blood ,if unable to aspirate blood from needle 46
  47. 47.  If doubt that needle has infiltrated, remove the needle to decrease vessel damage and apply ice  If patient has received heparin, leave the needle in place , apply ice and give protamine sulfate  Consider resting the access until infiltration and bruising has improved. (Follow unit policies)  The additional attempt must be done by an expert cannulator , if the dialysis is life saving and better use single needle dialysis (when available) 47
  48. 48. Securing of needles Needles should be secured at the same angle of insertion to avoid change in needle position and minimize risk of infiltration It also should be secured during treatment to avoid accidental malposition or dislodgment of needles Access limb and connections should be visible at all times and should not be covered with blankets. (Follow unit policies). 48
  49. 49. Needle Removal and Hemostasis Needles should be removed at the same angle of insertion Do not apply pressure while the needle is in the vein Once the needle is completely removed, use a 2- digit technique (one finger at the skin level and one at the vein level) for maximum hemostasis 49
  50. 50.  Dispose of the needle ( follow Occupational Health standards)  Make press at least for 10 min without releasing pressure (during applying pressure, ensure a thrill can be felt in the access)  If thrill cannot be felt, remove hand slowly and assess the thrill 50
  51. 51. Troubleshooting Needle Placement and increased venous and/ or arterial pressures. Decrease blood pump speed Measure blood pressure and review previous clinical records to determine baseline blood pressure, venous and arterial pressures and blood flow rate Assess thrill and bruit and observe for infiltration (swelling) 51
  52. 52.  Carefully reposition access limb  Use portable ultrasound to check position of needle prior to re-positioning or adjusting needle (if available)  Carefully adjust tape or place a small gauze under the needle wings (as needed), while closely monitoring venous and arterial pressures  If successful, secure needle in position with tape while monitoring venous and arterial pressures.52
  53. 53.  If unsuccessful, recirculate patient’s blood and recheck needle position with portable ultrasound If repositioning is unsuccessful, remove fistula needle  Before re-cannulation, ask help the clinical educator nurse  Repeat clinical assessment of AV access (thrill, bruit and portable ultrasound) prior to repeating cannulation.  Better to avoid repeated cannulation 53
  54. 54. Complicationsof Cannulation of Needle 2.During HD 1.During cannulation 3.On needle removal 54
  55. 55. During cannulation (extravasation) Needling an AVF which is too small, not mature enough, or very mobile can easily lead to extravasation, the needle may be inadvertently pierces through the side or back wall of the fistula. Signs and symptoms of extravasation include: 1.Pain 2.Swelling 3.Bruising. 55
  56. 56.  Extravasation is treated by applying pressure, ice, and administering analgesia.  Blown arterial needle with satisfactory flow can be used but extravasated venous needle should not be used for HD and use alternative access till the swelling subsides.  If extravasation is a usual problem, the patients should only be needled by experienced nurses with use of small-bore needles and referral for a surgical opinion. 56
  57. 57. 57 Problems during HD Needle dislodgement Can be identified by pressure alarms on the machine, bleeding from needle entry site, excessive pain, swelling and bruising May be resolved by adjusting the needle or by removing the needle and re-cannulation
  58. 58. 58 Suckling up of needle against the vessels wall Reduced arterial pressure and mild pain or vibration at the arterial needle site The needle will need to be rotated to
  59. 59. 59 Needles fall out during HD Result from poorly secured needle sites or excessive patient movement. Pressure on needle hole, stop HD and the extracorporeal re-circulated. Once haemostasis is achieved the patient may be re- cannulation and start HD.
  60. 60. 60 Problems following dialysis ( on needle removal) Delayed haemostasis Most common complication following HD Not turning off the heparin infusion soon enough Using too much heparin Inadequate pressure being applied on site of cannulation Pressure being taken off too soon following needle removal. If over-heparinization is suspected protamine may be administered.
  61. 61. 61 Cannulation Techniques Site-Rotation Buttonhole Known as: 1.Rope ladder 2.Rotating sites Known as: 1.Constant-site 2.Same-site
  62. 62. 62 Rope ladder ( Site- Rotation technique): Cannulation sites are rotated up and down the AVF to use its entire length with equal distribution of the puncture sites This is the classic technique used in most dialysis centers Cannulation in straight line at least 1–2cm for each cannulation site
  63. 63. 63 No need to ‘straighten out’ by pulling on the vessel to cannulates, the vessel will retract into its original position when released and lead to an infiltration Each treatment requires 2 new sites Disadvantage: Small dilatations over the whole fistula. Concerns of ‘ one-site-itis’
  64. 64. 64 Advantage: lower rate of infection Help expand the lifespan of the fistula. Changing cannulation site gives the previous needle site time to heal and decrease the chance of formation of aneurysms. It is thought rope ladder needling reduces the risk of stenosis.
  65. 65. 65
  66. 66. 66
  67. 67. 67
  68. 68. 68 “ONE-SITE–ITIS” Occurs when cannulates the needle in the same general area, session after session Causes aneurysm and stenosis formation
  69. 69. 69 Buttonhole Technique Method in which an individual cannulates the AV fistula in the exact same spot, at the same angle and depth of penetration every time After about 10 cannulations using sharp dialysis needles, the buttonhole site will develop a scar tunnel track. This track is the same as a pierced ear that has scar tissue formed and will cause less to no pain or bleeding when cannulated.
  70. 70. 70  After the buttonhole is created, a blunt dialysis needle should be used, which eliminates the risks of cuts and bleeding to the tract.
  71. 71. 71 ADVANTAGES May prolong AVF lifespan Reduce needling attempts Reduces pain Reduces bleeding and hematoma Reduces infiltration Reduces aneurysms Promotes self-care and self-dialysis Use blunt needles, which require no safety device
  72. 72. 72 DISADVANTAGES Requires same cannulator, same angle, same location High rate of infection Concerns of ‘one-site-its’ Difficult with fistula covered by: 1.Heavily scarred skin 2.Large amount of subcutaneous tissue
  73. 73. 73 Indications of buttonhole technique: Indication to use rope ladder technique • AVF is short in length or has short usable segments • AVF is relatively straight • AVF with tortuous anatomy • Patient has hand tremors. • AVF with aneurysmal dilatation • Poor vision or placement of needle on the BH lead to the creation of multiple tracts within the BH
  74. 74. 74 Indications of buttonhole technique: Indication to use rope ladder technique • AVF is difficult to cannulates (self cannulation) • Patient reports or demonstrates difficulty visualizing the BH site. • AVF is mature • Multiple tracts within the BH • Patient preference. • Needle phobia
  75. 75. 75 Complications of fistula
  76. 76. 76 1-Aneurysm , Pseudo aneurysm A consequence of an AV fistula creation is thickening and enlargement of the vein walls due to arterialization. Over time, flow in the fistula increases and the vein enlarges and may become tortuous. An aneurysm is a weak spot in the wall of the fistula which causes ballooning of the vessel wall.
  77. 77. 77  This aneurysm is secondary to repetitive cannulation in the same area (same=site itis) which lead to weakness of vessels walls  Pseudo aneurysm collection of blood in the tissue surrounding a vascular access can occur if improper control of bleeding after the dialysis needles is removed (pulsating extravascular hematomas).
  78. 78. 78  Aneurysm and pseudo aneurysm may also be caused by a proximal stenosis.  Patients with aneurysms may present to the emergency department reporting extremity pain, neurologic dysfunction secondary to aneurysmal impingement of surrounding nerves, significant thinning of overlying fistula skin, or hemorrhage secondary to this skin erosion
  79. 79. 79  Diagnosis  Both AV fistula aneurysm and pseudoaneurysms can be identified with the use of Doppler US.
  80. 80. 80  Management:  Changing needle sites and vascular surgery for operative repair.  Surgery is indicated when the aneurysmal dilatation is >2cm, pulsatile pain is present in the aneurysm, and the overlying skin appears glossy and discoloured (risk of rupture, perforation and ulceration)
  81. 81. 81 2-Infection: AV fistulas have lowest risk of infection of any vascular access type. Pre- cannulation must checking signs of infection over skin of AVF 1.Redness or raise temperature on exit site of fistula 2.Swelling or hardness. 3.Purulent discharge from needle sites. 4.Tenderness or pain.
  82. 82. 82 Causes Inadequate disinfection of the skin Contamination of the needle Manipulation of the needle during dialysis Scratching of the puncture site Poor personal hygiene Contamination due to bathing.
  83. 83. 83
  84. 84. 84  Management:  Must be managed urgently as it can lead to thrombosis or sepsis if left untreated.  Do not cannulates  Bloods cultures must be obtained and the access site swabbed to confirm diagnosis.  Antibiotics mostly necessary.  Patient may need admission and temporary dialysis access
  85. 85. 85  Prevention: 1. Pre and post treatment washing of access 2. No scratch on the access site 3. Appropriate skin antisepsis 4. Sufficient antiseptic-skin contact time 5. Cannulation while antiseptic is dry 6. Maintain needle sterility 7. Do not cannulate through scabs or abraded areas
  86. 86. 86 3-Thrombosis (clotting) The most common complications of AVF. Venous stenosis resulting in reduced blood flow, infection, recirculation, damage to the vessel wall, and eventually clotting of the fistula.
  87. 87. 87  Causes  Surgical/technical problems  Preexisting anatomic lesions  Premature use  Poor blood flow or hypotension  Hypercoagulation  Fistula compression (Patient compressing while sleeping)
  88. 88. 88 Clinical  Absence of pulse/thrill on palpation ( feel firm)  Absence of bruit on auscultation  No blood or blood clots can be aspirated
  89. 89. 89 Management ( Urgent treatment is required to prevent the failure of the access)  Do not needle  Take blood sample to see if HD necessary  Inform the nephrology team immediately.  Interventional thrombolysis  Surgical thrombectomy  Prophylactic surveillance (warfarin)  May require new access
  90. 90. 90 4-Bleeding Causes Bleeding after remove needle Anticoagulation/not stopping prior to end of HD Improper pressure with needle withdrawal Bleeding during treatment (oozing around needle or infiltration) = fragile vessel wall or back wall penetration  don’t flip the needles
  91. 91. 91 Symptoms and signs Needle sites bleed >10mins following HD
  92. 92. 92 Management:  Stop anticoagulation 1hr prior to the end of HD  Apply directed pressure  Consider coagulants (Protamine sulfate)  Review needle-removal technique  Review clotting disorder  Review medications and BP  Educate patients about post-treatment hemostasis and what to do at home ,if the needle site re-bleed
  93. 93. 93 5-Infiltration = Hematoma The pathological accumulations of substances in tissue or cells which are normally are absent. Causes: an improper needle flip or taping procedure can cause an infiltration.
  94. 94. 94  How to prevent the infiltration: During cannulation  Don’t flip needle  Don’t lift needle in vein  Check for flashback and aspirate  Flush with NSS to ensure, that there are no signs or symptoms of infiltration (Saline causes much less damage and discomfort than blood if an infiltration occurs)
  95. 95. 95 Post hemodialysis Apply gauze without pressure during removal of needle Remove needle at insertion angle Apply pressure with 2 fingers Hold pressure 10–12 minutes
  96. 96. 96 Management of infiltration:  Elevate arm above heart  Ice 20 minutes on/20 minutes off for 24 hours  Warm compresses after 24 hours  Let fistula rest  Second infiltration: Notify vascular access team
  97. 97. 97 Hematoma  If bruising or hematoma occurs after dialysis, the surface skin site has sealed but the needle hole in the vessel wall has not.  Use 2 fingers per site for hemostasis  It is crucial to apply pressure to both the skin and access wall puncture sites
  98. 98. 98 6-Poor arterial flow and increased venous pressure May be due to location or position of needle May be there are thrombosis or stenosis or significant recirculation. This poor flow may lead to clotting of the AVF.
  99. 99. 99  Management:  An angiogram or Doppler US should be performed to detect stenosis or thrombosis.  Recirculation tests can also be used to determine the significance of venous stenosis.  Recirculation >10–15% suggests access malfunction.  R = {(P – A) / (P – V)}x 100  P= BUN periphery, A= BUN arterial line, V= BUN venous line and R =the percentage recirculation
  100. 100. 100 7-Stenosis: Most common complication Hyperplasia in lumen (usually arterial side) Frequent cause of fistula failure Causes: Surgery to create AVF Turbulence-Pseudoaneurysm-aneurysms Needle-stick injury
  101. 101. 101  Type of stenosis: 1-Juxta-anastomotic (most common stenosis in AVF) 2-Mid-access stenosis 3-Outflow stenosis 4-Central vein stenosis
  102. 102. 102 Clinical key that there is stenosis:  Clotting of the extracorporeal circuit 2 or more times/month  Persistently swollen access extremity  Changes in bruit or thrill (ie, becomes pulse-like)  Difficult needle placement  Blood squirts out during cannulation  Elevated venous pressures
  103. 103. 103  Inability to achieve optimum blood flow rate.  Changes in Kt/V and URR  Recirculation  Prolonged postdialysis bleeding  Presences of frequent episodes of access clotting
  104. 104. 104  Diagnosis  Physical examination and/or flow measurement should be performed as soon as possible.  Duplex scan/fistulagram.  MRA should be performed  Recirculation studies R = ([P - A] / [P – V]) x 100 Where P= BUN periphery, A= BUN arterial line, V= BUN venous line and R =the percentage
  105. 105. 105 Parameter Normal Stenosis Thrill Only at the arterial anastamosis At site of stenotic lesion Pulse Soft, easily compressible Water-hammer Bruit Low pitch, Continuous Diastolic & systolic High pitch, Discontinuous Systolic only
  106. 106. 106 Management Call surgical team for corrective treatment: Percutaneous trans-luminal angioplasty is the first treatment option for venous outflow stenosis. Radiological intervention ( stent or balloon dilatation) Surgical revision. Temporary access
  107. 107. 107  Steal syndrome: Deprivation of blood distal to AVF/AVG Steal syndrome (ischemia of the hand)  Inadequate blood supply to the hand, caused by the AVF “stealing” blood away from the extremity, this causes hypoxia (lack of oxygen) to the tissues of the hand resulting in severe pain and neurologic damage to the hand can occur.
  108. 108. 108 Risk factors  Brachial arterial origin  Diabetes mellitus  Peripheral vascular disease (PVD)  Female gender
  109. 109. 109  Clinical picture:  Most patients are asymptomatic  Cold sensation and pale colour of the fingers  Ischemic pain  Diminished or absent pulses  Capillary refill will decrease  Neurological and soft tissue damage to the hand can occur, resulting in mobility limitations (eg, grip strength, skill), loss of function, ulcerations, necrosis
  110. 110. 110
  111. 111. 111 Diagnosis of Steal Syndrome Clinical investigation –Allen test. Noninvasive imaging tests: measurement of digital pressures and access flow measurements. Angiography Pulses, BP, pulse oximetry, Doppler, duplex US should be carried out.
  112. 112. 112 Allen test.  A medical sign used in physical examination of arterial blood flow to the hands.  The hand is normally supplied by blood from both the ulnar artery on the little finger-side and the radial artery on the thumb-side.
  113. 113. 113  These two arteries connect to form an anastomosis, so if one of the arteries becomes compressed or occluded, the blood supply from other artery will maintain the blood supply of hand  Compressing both the radial and ulnar arteries simultaneously (30 second ) while patient open and close his hand, allowing the blood to drain via the venous system, causing the hand to blanch.
  114. 114. 114  While the patient opens and closes his hand, release one of the arteries, evaluating how fast refill occurs to the hand.  Repeat the procedure again, this time releasing the other artery while timing the refill.  Refilling of less than 3 seconds is considered a negative test and indicates there is adequate blood flow in the palmer
  115. 115. 115
  116. 116. 116 Management of Steal Syndrome  Early referral to the surgical for revision of access  the DRIL distal revascularization-interval ligation, can successfully treat steal and ischemia  Pain control.  Encourage patient to wear a glove on affected extremity.  Steal symptoms may improve due to the development of collateral circulation.
  117. 117. 117 Examination of the mature hemodialysis arteriovenous fistula Examination of the mature hemodialysis arteriovenous fistula
  118. 118. 118  Routine physical examination of the fistula lead to early detection and treatment of any problems  The 2006 National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF- K/DOQI) guidelines and the 2008 Society for Vascular Surgery practice guidelines recommend that physical examination must be performed on all mature arteriovenous fistulas (AVFs)
  119. 119. 119  Examination must be done every hemodialysis treatment.  Must be known by all clinical staff who dealing with fistula  It is easy  Inexpensive  To detect common problems associated with hemodialysis access
  120. 120. 120  Inspection  Position of the fistula 1. Radiocephallic 2. Brachiocephallic 3. Transposed cephallic  Presence of other vascular access 1. Central venous access 2. Peritoneal access 3. Graft
  121. 121. 121  Expose the entire extremity with the AV access  Compare any change in the limb to the non-access limb  Signs of infection (warmth, erythema, discharge ...)  Presence of bruising (hematoma) , swelling (edema), and collateral veins (visualize entire arm and upper chest)  Aneurysm and pseudoaneurysm
  122. 122. 122  Outflow stenosis (Arm Elevation Test): When the access arm is elevated to a level above the heart. o The absence of a stenosis, the vein where the blood flows out (Should collapse , Become less prominent) o If a stenosis is present, the portion of the fistula distal to point of stenosis remains distended, while the proximal portion collapses
  123. 123. 123
  124. 124. 124  Access-induced ischemia or steal syndrome (signs of cyanosis of the finger tips and delayed capillary refill of the nail beds, hand pallor and decreased range of motion)  Location of anastomosis and evidence of healing incision lines  Skin integrity (rash, blisters, scabs or eroded cannulation sites)
  125. 125. 125  Appropriateness of vessel size (depth and diameter) for cannulation suitability  Location for previous cannulation sites (avoid thin, white, shiny aneurysmic areas).  Central venous stenosis: (If generalized swelling of the arm and/or collateral veins on the upper limb is identified, the possibility of central venous stenosis needs to be ruled out)
  126. 126. 126  Palpation for AV fistula  Evaluate for possible cannulation sites = superficial, straight vein section with adequate and consistent vein diameter  Feeling of fistula  Use a two- or three-finger approach to roll fingers across the AV fistula to determine width and depth of access  Check for tenderness
  127. 127. 127  Pulse o Normal AVF is soft, compressible and non- pulsatile o A pulsatile fistula is suggestive of obstruction or stenosis (venous side). o The strength of the pulse is related to the severity of this obstruction
  128. 128. 128
  129. 129. 129  Temperature Change  Feel the access skin temperature o Warmth = possible infection o Cold = decreased blood supply  Assess and compare temperatures in both the access and non-access limb.
  130. 130. 130  The thrill must be assessed by palpating the entire length of the AV fistula to determine access patency (The vein should be soft and easy to compress)  Normally a thrill has a systolic and a diastolic component  A thrill is a buzzing or vibration felt (soft continuous thrill)the blood flow created by the high pressure arterial system merging with the low pressure venous system}
  131. 131. 131  A strong thrill should be palpable at the arterial anastomosis diminishing distally, closer to the venous end.  Change can be felt at the site of a stenosis; becomes ‘pulse-like’ at the site of a stenosis  A weak thrill may suggest a stenosis at or near the anastamosis (arterial side)
  132. 132. 132  Occasionally, a thrill can be palpated in the axillary or subclavian region, particularly in thin chested individuals and may suggest presence of central venous stenosis.
  133. 133. 133  Pulse augmentation test ( for inflow stenosis)  The normal AV access is soft and compressible but non-pulsatile.  If the access occluded several centimeters above the anastomosis, there should be augmentation of the pulse in the distal portion.  The degree of this “pulse augmentation” is proportional to arterial inflow pressure, making this maneuver, an excellent tool to diagnose inflow problems.
  134. 134. 134  If the pulse augmentation is poor ( weak or absent pulse with obstruction )  poor arterial inflow
  135. 135. 135 Auscultation  Listen for Bruit  Begin at the AV anastomosis and continue along the length of the access noting any changes in pitch and amplitude of the bruit.  Bruit: A well-functioning fistula should have continuous, machinery-like bruit on auscultation (low- pitched whooshing of blood through the fistula heard through a stethoscope) created by the turbulence at the
  136. 136. 136  An obstructed (stenotic) fistula may have a discontinuous and pulse-like bruit rather than a continuous one and also may be louder and high- pitched or ‘whistling’ Louder at stenosis than at anastomosis  Absent bruit usually indicates that the access has clotted or thrombosed.  NO bruit – NO cannulation  Portable ultrasound to make good report about AVF.
  137. 137. 137
  138. 138. 138

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