Scottish Renal Nursing Strategy Group

Best Practice Statement

for the care of Arterio-Venous Fistula and Graft

This Best Practice Statement has been printed with financial and professional support from NHS Quality Improvement Scotland

1

Contents

Introduction to the statement 2

Section 1: Pre-dialysis preparation and care Section 2: Pre-operative preparation and care Section 3: Post-operative preparation and care

Section 4: Access surveillance Section 5: Cannulation Section 6: Patient information

4 5 6 7 8

12

Appendix 1/1a: Pre-operative care good practice example 13

Appendix 2: Post-operative care good practice example 15

Appendix 3: Guidelines non-functioning vascular access good practice example

17

Appendix 4: Cannulation of vascular access 18

Appendix 5: Blood flow rates & needle gauge 20

Appendix 6: Patient information 21

Glossary 22

References 24

Who was involved in developing the statement? 25

2

Introduction to the statement Over the last few years, there has been an increase in the prevalence of renal replacement therapy (RRT) for patients who reach established renal failure. The Scottish Renal Registry report of 2006 indicates that the prevalence of new patients starting renal replacement therapy has continued to increase. The annual take-in rate is approximately 600 per year. Co-morbidity has risen considerably requiring increased nursing intervention. There are ten adult renal units in Scotland with nine satellite or annexe units. In addition there is one paediatric renal unit. The Scottish Renal Nursing Strategy Group has committed to looking at ways in which the services can be developed. The largest growth area is haemodialysis. The philosophy of this group is to identify nursing priorities for renal services within Scotland to provide clear direction for nurses working within the specialty. The strategy will be developed in collaboration with representatives from all Scottish Renal units and in consultation with relevant national groups. The purpose of this best practice statement is to guide all haemodialysis nursing and technical staff in the best way to manage and preserve vascular access. Poor vascular access for haemodialysis may contribute to increased risk of infection, unnecessary repeated admissions to hospital and potentially increased mortality. The National Service Framework for Renal Services suggests that: • all children, young people and adults approaching established renal failure are

to receive timely preparation for renal replacement therapy, so the complications and progression of their disease are minimised, and their choice of clinically appropriate treatment options maximised (standard 2)

• all children, young people and adults with established renal failure are to have

timely and appropriate surgery for vascular or peritoneal access, which is monitored and maintained to achieve maximum longevity (standard 3)

Scottish Renal Association and NHS Quality Improvement Scotland (NHS QIS) standards require that: • 70% of established patients should have functioning arterio-venous fistula or

graft • 60% of new starts should have functioning arterio-venous fistula if known to renal service for more than 3 months. Why fistula first The arterio-venous fistula (AVF) remains the gold standard access to haemodialysis, showing better survival and lower complication rates than grafts and catheters (Brunori et al, 2005). The presence of a catheter and/or its complications may affect the longevity of a native fistula through its earlier utilisation or less favourable maturation (Rayner et al, 2003). The Dialysis

3

Outcomes Quality Initiative (DOQI) guideline 3 states that in order to determine which type of access is most suitable to the individual patient, an evaluation of the patient’s venous, arterial and cardiopulmonary systems must be performed. Previous placement of central venous catheter is associated with central venous stenosis. Central venous catheters should be discouraged as permanent vascular access. In the absence of factors associated with contraindications for the formation of AVF, this would be the first preference for vascular access (DOQI, 2000). Premature cannulation of a fistula may result in a higher incidence of infiltration with associated compression of the vessel by haematoma and permanent loss of the fistula (DOQI guideline 9, 2000). The AVF/graft should be: • patent • palpable with bruit present • clean and free from signs of infection • able to deliver adequate haemodialysis The success of vessel access is best assessed by its capability to supply and return blood to the general circulation at acceptable flow rates, its duration of effective function, the degree of patient discomfort and limitation, and the rate and severity of complications.

Sect

ion

1:

Pre-

dial

ysis

pre

para

tion

and

care

K

ey p

oint

: Fr

eque

nt m

onito

ring

of fi

stul

a pa

ram

eter

s is

requ

ired.

Stat

emen

t R

easo

n fo

r sta

tem

ent

How

is it

bei

ng a

chie

ved

Ref

erra

l for

vas

cula

r acc

ess

at th

e pr

e-di

alys

is s

tage

sho

uld

be m

ade

whe

n th

e pa

tient

is a

ppro

xim

atel

y si

x m

onth

s to

one

yea

r aw

ay fr

om

dial

ysis

.

Pro

gres

sion

can

be

depe

nden

t on

indi

vidu

al d

isea

se p

rogr

essi

on

(O’H

are

et a

l 200

7).

To e

nabl

e pl

anne

d in

terv

entio

n en

surin

g be

st p

erm

anen

t ac

cess

with

few

er c

ompl

icat

ions

.

This

will

als

o al

low

for a

ny re

med

ial i

nter

vent

ion

if re

quire

d.

By

impl

emen

tatio

n of

loca

l pat

ient

pat

hway

and

au

dit.

The

site

of f

istu

la s

houl

d be

iden

tifie

d an

d al

l oth

er c

o-m

orbi

ditie

s sh

ould

be

cons

ider

ed.

To re

duce

inco

nven

ienc

e to

the

patie

nt a

nd fa

cilit

ate

easi

er

care

of f

istu

la s

ite.

To fa

cilit

ate

easi

er a

cces

s of

the

fistu

la d

urin

g ca

nnul

atio

n.

To id

entif

y op

timum

site

for a

fist

ula.

By

mai

ntai

ning

and

sup

porti

ng, o

pen

com

mun

icat

ion

betw

een

patie

nt, n

ursi

ng s

taff

and

surg

eon.

Sta

ff ar

e ab

le to

iden

tify

best

pos

sibl

e fis

tula

site

s.

Pat

ient

s re

quiri

ng v

ascu

lar a

cces

s fo

r ha

emod

ialy

sis

shou

ld h

ave

thei

r vei

ns

pres

erve

d an

d no

t util

ised

for a

ny

inte

rven

tion

befo

re a

cces

s is

cre

ated

.

If ve

ssel

s ar

e ac

cess

ed fr

eque

ntly

for v

enep

unct

ure

the

vess

el b

ecom

es fr

agile

and

may

not

be

sust

aina

ble

as

adeq

uate

vas

cula

r acc

ess

for h

aem

odia

lysi

s.

Onc

e it

is id

entif

ied

that

the

patie

nt re

quire

s ac

cess

sur

gery

, all

heal

thca

re w

orke

rs s

houl

d be

ad

vise

d th

at v

esse

ls o

n “fi

stul

a” a

rm a

re n

ot u

sed

for v

enep

unct

ure/

cann

ulat

ion

or fo

r blo

od

pres

sure

.

The

patie

nt/a

dvoc

ate

shou

ld b

e ad

vise

d of

car

e of

ve

ssel

s.

Dur

ing

inpa

tient

sta

y a

loca

l mea

ns o

f id

entif

icat

ion

is a

pplie

d to

indi

cate

that

this

arm

sh

ould

not

be

used

for v

enep

unct

ure/

cann

ulat

ion

or b

lood

pre

ssur

e m

easu

rem

ent.

Key

cha

lleng

e:

Ens

urin

g re

ason

s fo

r fai

lure

to p

rogr

ess

to th

eatre

are

doc

umen

ted

and

actio

n pl

an is

impl

emen

ted.

4

Sect

ion

2

Pre-

oper

ativ

e pr

epar

atio

n an

d ca

re

Key

poi

nts:

M

inim

um o

f ure

a, e

lect

roly

tes,

full

bloo

d co

unt a

nd c

lotti

ng s

cree

n m

ust b

e ch

ecke

d be

fore

thea

tre.

Fist

ula

map

ping

may

be

impl

emen

ted

at ti

me

of s

urge

ry.

Stat

emen

t R

easo

n fo

r sta

tem

ent

How

is it

bei

ng a

chie

ved

The

patie

nt s

houl

d be

edu

cate

d re

gard

ing

acce

ss fo

rmat

ion

usin

g a

sele

ctio

n of

evi

denc

ed

base

d m

ater

ial t

ailo

red

to s

uit t

he

indi

vidu

al n

eeds

of t

he p

atie

nt.

To e

mpo

wer

the

patie

nt to

mak

e in

form

ed

deci

sion

s ab

out t

he fo

rthco

min

g pr

oced

ure

and

enco

urag

e pa

rtici

patio

n in

reco

mm

ende

d tre

atm

ent (

CS

BS

, sta

ndar

d 12

, 200

2).

Des

igna

ted

pers

on p

rovi

des

info

rmat

ion,

adv

ice

and

supp

ort f

or

patie

nt a

nd c

arer

whe

re a

ppro

pria

te b

efor

e ac

cess

form

atio

n.

A re

cord

is k

ept o

f inf

orm

atio

n di

strib

uted

to p

atie

nts

in th

e pr

e-di

alys

is p

erio

d.

Per

i-ope

rativ

e ca

re s

houl

d be

im

plem

ente

d as

per

loca

l pr

otoc

ol.

To e

nsur

e pa

tient

sui

tabi

lity

and

safe

ty d

urin

g pe

ri-op

erat

ive

perio

d.

Impl

emen

tatio

n of

loca

l pro

toco

l (ap

pend

ix 1

& 1

a).

Sta

ff in

volv

ed in

the

peri-

oper

ativ

e pe

riod

are

fam

iliar

with

loca

l pr

otoc

ol m

inim

um s

houl

d in

clud

e:

ge

nera

l hea

lth re

view

bloo

ds

dr

ugs

bl

ood

pres

sure

5

Sect

ion

3

Post

-ope

rativ

e pr

epar

atio

n an

d ca

re

Stat

emen

t R

easo

n fo

r sta

tem

ent

How

is it

bei

ng a

chie

ved

Pos

t-ope

rativ

e ca

re -

follo

win

g su

rger

y, a

ll pa

tient

s w

ill re

quire

m

onito

ring

of th

eir f

istu

la/g

raft.

Ear

ly d

etec

tion

of c

ompl

icat

ions

. To

mai

ntai

n A

VF/

graf

t pat

ency

. O

bser

vatio

ns a

re p

erfo

rmed

in a

ccor

danc

e w

ith lo

cal p

roto

col a

nd th

e ne

eds

of th

e in

divi

dual

pat

ient

(app

endi

x 2

& 2

a).

Pat

ency

of f

istu

la s

houl

d be

doc

umen

ted.

The

patie

nt is

giv

en a

vaila

ble

advi

ce fo

llow

ing

AV

F/ve

in g

raft

surg

ery.

To e

nsur

e th

at s

taff

and

patie

nt

are

awar

e of

the

appr

opria

te

afte

r car

e fo

llow

ing

acce

ss

form

atio

n.

Loca

l dev

elop

men

t of p

ost-o

pera

tive

guid

elin

es.

Cle

ar a

nd c

onci

se in

form

atio

n an

d ad

vice

sho

uld

be g

iven

rega

rdin

g co

ntin

uing

car

e an

d m

aint

enan

ce o

f fis

tula

pat

ency

(Ode

r,TF

et a

l 200

3).

Key

cha

lleng

es:

Ens

urin

g co

mpr

ehen

sive

trai

ning

and

edu

catio

n of

sta

ff.

E

nsur

ing

that

rele

vant

info

rmat

ion

rega

rdin

g ca

re o

f vas

cula

r acc

ess

acco

mpa

nies

all

patie

nts

to n

on-r

enal

are

as.

6

Sect

ion

4 A

cces

s Su

rvei

llanc

e K

ey p

oint

s:

Pat

ient

sho

uld

be a

sses

sed

pre-

oper

ativ

ely

and

post

ope

rativ

ely.

Ther

e ar

e di

ffere

nt s

tage

s in

the

proc

ess

and

to e

nsur

e ad

equa

te s

urve

illan

ce th

ese

step

s sh

ould

be

follo

wed

.

Stat

emen

t R

easo

n fo

r sta

tem

ent

How

is it

bei

ng a

chie

ved

All

patie

nts

shou

ld h

ave

vasc

ular

as

sess

men

t prio

r to

surg

ery.

To

ass

ess

pate

ncy,

ves

sel s

ize

and

suita

bilit

y fo

r cre

atio

n of

vas

cula

r ac

cess

.

• at

tend

des

igna

ted

vasc

ular

clin

ic

• du

plex

sca

n •

pre-

adm

issi

on a

sses

smen

t •

date

for s

urge

ry.

All

new

vas

cula

r acc

ess

shou

ld b

e re

view

ed w

ithin

48

hour

s of

sur

gery

by

app

ropr

iate

hea

lth p

rofe

ssio

nal.

To a

sses

s su

cces

s of

sur

gery

. Pr

e-di

alys

is p

atie

nts:

•

follo

w-u

p, 4

8 ho

urs

post

-sur

gery

as

per l

ocal

pro

toco

l.

Es

tabl

ishe

d di

alys

is p

atie

nts:

•

revi

ew w

ithin

48h

rs o

f sur

gery

by

seni

or n

urse

or n

ephr

olog

ist.

All

patie

nts:

•

follo

w-u

p, v

ascu

lar a

cces

s cl

inic

with

in s

ix w

eeks

(Kon

ner K

et a

l 20

03).

• re

peat

Dup

lex

scan

if re

quire

d.

Can

nula

tion

diffi

culti

es m

ay o

ccur

in

new

ly e

stab

lishe

d fis

tula

.

Re-

asse

ssm

ent o

f vas

cula

r acc

ess

may

be

requ

ired.

•

disc

uss

with

dia

lysi

s nu

rse

diffi

culti

es e

xper

ienc

ed d

urin

g ca

nnul

atio

n •

refe

r to

vasc

ular

acc

ess

nurs

e or

nep

hrol

ogis

t •

dupl

ex s

can

• re

-ref

er to

sur

geon

.

Rou

tine

surv

eilla

nce

of v

ascu

lar

acce

ss s

houl

d be

und

erta

ken

and

docu

men

ted.

Bea

thar

d G

200

3).

Ear

ly d

etec

tion

and

treat

men

t of

pote

ntia

l pro

blem

s w

ith e

stab

lishe

d va

scul

ar a

cces

s.

Pre-

dial

ysis

pat

ient

s:

• ro

utin

ely

asse

ss a

t low

cle

aran

ce c

linic

, onl

y re

ferr

ed b

ack

to

vasc

ular

acc

ess

nurs

e if

com

plic

atio

n oc

curs

. Es

tabl

ishe

d di

alys

is p

atie

nts:

•

min

imum

6 m

onth

ly b

lood

flow

mon

itorin

g/re

circ

ulat

ion/

trans

onic

•

rout

ine

mon

itorin

g of

arte

rial a

nd v

enou

s pr

essu

re

• hi

ghlig

ht a

ny c

ompl

icat

ion

to v

ascu

lar a

cces

s nu

rse/

neph

rolo

gist

s •

inte

rven

tiona

l Rad

iolo

gist

. w

ww

.vas

cula

racc

esss

ocie

ty.c

om/g

uide

lines

Pat

ient

s w

ith u

nexp

ecte

d no

n-fu

nctio

ning

vas

cula

r acc

ess.

R

escu

e va

scul

ar a

cces

s w

ithou

t de

lay.

•

emer

genc

y ad

mis

sion

pro

toco

l •

imm

edia

te re

ferr

al t

o va

scul

ar a

cces

s nu

rse/

neph

rolo

gist

s •

refe

r to

surg

eon

or in

terv

entio

nal r

adio

logi

st.

App

endi

x 3

Key

cha

lleng

e:

Ens

urin

g th

at re

leva

nt in

form

atio

n re

gard

ing

care

of v

ascu

lar a

cces

s ac

com

pani

es a

ll pa

tient

s to

non

-ren

al a

reas

.

7

Sect

ion

5

Can

nula

tion

Stat

emen

t R

easo

n fo

r sta

tem

ent

How

is it

bei

ng a

chie

ved

New

fist

ula

shou

ld b

e ex

amin

ed b

y ne

phro

logi

sts/

vasc

ular

sur

geon

or

desi

gnat

ed s

enio

r ren

al n

urse

prio

r to

first

ca

nnul

atio

n.

It is

ess

entia

l tha

t vas

cula

r acc

ess

shou

ld b

e:

• fre

e fro

m re

dnes

s •

free

from

sig

ns o

f inf

ectio

n •

brui

t is

pres

ent.

Stri

ct a

sept

ic te

chni

que

shou

ld b

e us

ed to

cl

ean

the

fistu

la s

ite p

rior t

o ca

nnul

atio

n, n

on-

ster

ile g

love

s sh

ould

be

wor

n du

ring

the

proc

edur

e

Firs

t and

sub

sequ

ent c

annu

latio

ns w

hile

fis

tula

is d

evel

opin

g ar

e pe

rform

ed b

y de

sign

ated

sta

ff m

embe

rs.

Cho

ice

of s

ites

is u

sual

ly d

eter

min

ed b

y th

e se

nior

rena

l nur

se.

Use

2 x

17-

gaug

e ne

edle

s O

R if

dia

lysi

s ca

thet

er in

pla

ce 1

x 1

7-ga

uge

need

le fo

r ar

teria

l lin

e an

d ca

thet

er a

s ve

nous

retu

rn

line.

Kee

p ne

edle

s a

min

imum

of 1

.5-2

cm

aw

ay fr

om a

nast

omos

is u

nles

s us

ing

butto

nhol

e te

chni

que.

To e

stab

lish

read

ines

s fo

r can

nula

tion.

To e

nsur

e co

ntin

uity

and

can

nula

tion

by s

taff

with

sui

tabl

e le

vel o

f kno

wle

dge

and

dem

onst

ratin

g be

st p

ract

ice

cann

ulat

ion

tech

niqu

e.

To p

reve

nt b

leed

ing

into

sur

roun

ding

tiss

ue.

To p

reve

nt c

onta

min

atio

n an

d m

inim

ise

trans

fer o

f ski

n flo

ra d

urin

g ca

nnul

atio

n pr

oces

s.

Aqu

eous

chl

orhe

xidi

ne 0

.25%

- 2%

is

reco

mm

ende

d fo

r cle

anin

g th

e fis

tula

site

.

All

patie

nts

shou

ld w

ash

thei

r han

ds a

nd

fistu

la a

rm w

hen

they

arr

ive

at th

e di

alys

is

unit.

To p

reve

nt d

evel

opm

ent o

f pse

udo-

aneu

rysm

use

of ro

pe la

dder

or b

utto

nhol

e ca

nnul

atio

n is

reco

mm

ende

d (B

all L

200

6).

Sm

all g

auge

nee

dles

to m

inim

ise

risk

of

infil

tratio

n, m

inim

um d

ista

nce

away

from

an

asto

mos

is to

pre

vent

dam

age

to

anas

tom

osis

.

Loca

l pol

icy

in p

lace

for

exam

inat

ion

of n

ew fi

stul

a.

App

endi

x 4

Loca

l pol

icy

in p

lace

and

m

echa

nism

for a

ssig

nmen

t of

sta

ff to

initi

al c

annu

latio

n.

Loca

l hep

arin

pol

icy

in p

lace

. Lo

cal p

olic

y in

pla

ce, s

taff

and

patie

nt e

duca

tion

on

hand

was

hing

. U

se o

f KD

OQ

I (20

00)

guid

elin

es.

Loca

l Pol

icy

in p

lace

. S

taff

educ

atio

n.

Aud

it.

8

A to

urni

quet

sho

uld

be a

pplie

d to

the

uppe

r ar

m s

o th

at it

is ti

ght e

noug

h to

dila

te th

e ve

ssel

or i

mpe

de v

enou

s ou

tflow

(Bal

l L

2005

).

The

patie

nt m

ay b

e en

cour

aged

to g

rip th

eir

fistu

la a

rm in

stea

d of

usi

ng a

tour

niqu

et.

Gen

tly p

ull t

he s

kin

in th

e op

posi

te d

irect

ion

to th

e ne

edle

inse

rtion

and

can

nula

te th

e fis

tula

usi

ng a

25-

degr

ee a

ngle

, with

the

beve

l of t

he n

eedl

e U

P. T

ape

need

le a

t the

an

gle

of in

serti

on

DO

NO

T fla

tten

agai

nst t

he s

kin;

sta

bilis

e th

e bu

tterfl

y w

ith ta

pe a

nd s

ecur

e

Nev

er fo

rce

the

need

le a

gain

st re

sist

ance

to

com

plet

ely

flatte

n th

e an

gle

befo

re s

ecur

ing

the

win

gs

Nur

sing

sta

ff m

ust b

e m

ade

awar

e of

the

impo

rtanc

e of

sec

urin

g ne

edle

s.

Tape

nee

dle

exte

nsio

ns a

nd li

nes

in a

loop

to

the

PA

TIE

NT,

NE

VE

R to

the

chai

r or p

illow

. In

stru

ct p

atie

nt n

ot to

mov

e ac

cess

ext

rem

ity.

Use

blo

od fl

ow ra

te o

f 200

ml/m

in M

AX

and

re

duce

to 1

80m

l/min

if n

ot to

lera

ted,

incr

ease

bl

ood

flow

rate

s O

NLY

if in

filtra

tion

or o

ther

pr

oble

ms

are

not n

oted

. M

ap th

e fis

tula

and

can

nula

tion

site

s us

ed,

repo

rt an

y pr

oble

ms

to d

esig

nate

d va

scul

ar

acce

ss n

urse

/nep

hrol

ogis

ts/s

urge

on/

radi

olog

ist.

If fir

st w

eek

is s

ucce

ssfu

l con

tinue

to w

eek

2 ch

angi

ng to

16-

gaug

e ne

edle

s, ro

tatin

g ca

nnul

atio

n si

tes

and

incr

easi

ng b

lood

flow

Com

pres

ses

perip

hera

l ner

ve e

ndin

gs

betw

een

epid

erm

is a

nd d

erm

is w

ith le

ss s

kin

surfa

ce a

rea

cont

actin

g cu

tting

edg

e of

ne

edle

.

Sta

bilis

es a

cces

s an

d di

late

s fis

tula

, bev

el

UP

to e

nsur

e cu

tting

edg

e of

nee

dle

agai

nst

the

skin

, and

faci

litat

es s

moo

ther

inci

sion

of

skin

.

Less

ste

ep a

ngle

s in

crea

se ri

sk o

f dra

ggin

g cu

tting

edg

e of

nee

dle

alon

g su

rface

of

vess

el. S

teep

er a

ngle

s in

crea

se ri

sk o

f pe

rfora

ting

unde

rsid

e of

ves

sel.

Pre

ssin

g th

e ne

edle

sha

ft fla

t aga

inst

the

skin

m

oves

the

need

le ti

p fro

m th

e de

sire

d po

sitio

n w

ithin

the

vess

el lu

men

.

To p

reve

nt s

wel

ling

and

dam

age

to th

e fis

tula

sh

ould

infil

tratio

n oc

cur.

Blo

od fl

ow ra

te s

houl

d be

mat

ched

with

the

corr

ect n

eedl

e ga

uge.

To a

void

trau

ma

to th

e in

tima

of th

e ve

ssel

. To

pre

vent

dis

plac

emen

t of n

eedl

es a

nd th

us

prev

ent i

nfilt

ratio

n an

d ha

emor

rhag

e.

To d

emon

stra

te c

annu

latio

n hi

stor

y.

Take

n fro

m K

DO

QI (

2000

).

Loca

l pol

icy.

S

taff

educ

atio

n.

See

tabl

e fo

r BFR

and

ne

edle

gau

ges.

Lo

cal p

olic

y.

Sta

ff/pa

tient

edu

catio

n.

Aud

it of

fist

ula

care

/ ex

amin

atio

n.

If bl

eedi

ng is

pro

long

ed

revi

ew h

epar

in p

resc

riptio

n.

Loca

l pol

icy.

S

taff/

patie

nt e

duca

tion.

9

rate

. W

eek

3: a

s w

eek

2 or

if to

lera

ted

wel

l in

crea

se to

14/

15-g

auge

nee

dles

and

re

quire

d B

FR.

Infil

tratio

n gu

idel

ines

: •

if th

e fis

tula

infil

trate

s le

t it r

est f

or 1

wee

k th

en g

o ba

ck to

sm

alle

r gau

ge n

eedl

es.

Not

ify v

ascu

lar a

cces

s nu

rse/

neph

rolo

gist

• if

it in

filtra

tes

a se

cond

tim

e re

st fo

r 2

wee

ks a

nd th

en re

duce

nee

dle

size

. N

otify

vas

cula

r acc

ess

nurs

e/ne

phro

logi

st

•

if in

filtra

tion

occu

rs a

third

tim

e no

tify

desi

gnat

ed v

ascu

lar a

cces

s nu

rse/

co-

ordi

nato

r/nep

hrol

ogis

t/rad

iolo

gist

/ su

rgeo

n.

To re

ach

optim

um d

eliv

ered

blo

od fl

ow a

nd

dial

ysis

ade

quac

y.

To p

reve

nt fu

rther

dam

age

to fi

stul

a, a

nd

allo

w h

ealin

g.

Con

secu

tive

infil

tratio

n co

uld

sign

ify a

pr

oble

m w

ith th

e fis

tula

whi

ch re

quire

s ra

diol

ogic

al o

r sur

gica

l int

erve

ntio

n.

Loca

l pol

icy.

A

ccur

ate

docu

men

tatio

n at

al

l sta

ges.

A

ppen

dix

5

10

Nee

dles

for v

ascu

lar a

cces

s sh

ould

be

secu

red

with

app

ropr

iate

tran

spar

ent

dres

sing

/tape

. C

annu

latio

n si

tes

shou

ld b

e m

onito

red

thro

ugho

ut th

e di

alys

is s

essi

on.

Dia

lysi

s lin

es s

houl

d be

sec

ured

to th

e pa

tient

’s a

rm o

r clo

thin

g N

OT

the

pillo

w o

r ar

m re

st.

Nee

dles

sho

uld

be s

ecur

ed to

ens

ure

that

th

ere

is n

o cl

inic

al ri

sk to

pat

ient

. M

ovem

ent o

f nee

dles

may

resu

lt in

trau

ma

to

fistu

la a

nd/o

r hae

mor

rhag

e.

To re

duce

the

risk

of n

eedl

e di

slod

gem

ent.

To a

void

acc

iden

tal d

islo

dgem

ent.

Sta

ff/pa

tient

edu

catio

n an

d tra

inin

g.

Pre

ssur

e sh

ould

be

appl

ied

for a

t lea

st 1

0 m

inut

es w

ithou

t bei

ng re

leas

ed. C

lam

ps

shou

ld n

ot b

e us

ed.

Nee

dles

sho

uld

be re

mov

ed a

t the

sam

e an

gle

as in

serti

on. F

irm b

ut g

entle

pre

ssur

e sh

ould

be

appl

ied

AFT

ER

the

need

le h

as

been

com

plet

ely

rem

oved

from

the

vess

el.

To a

llow

tim

e fo

r clo

t for

mat

ion

to o

cclu

de th

e pu

nctu

re s

ite a

nd to

pre

vent

bru

isin

g fro

m

seep

age

unde

r the

ski

n be

twee

n th

e sk

in

surfa

ce a

nd th

e ve

ssel

wal

l. C

lam

ps c

ould

da

mag

e th

e fis

tula

as

ther

e is

no

cont

rol o

n th

e am

ount

of p

ress

ure

bein

g us

ed th

us th

e fis

tula

cou

ld b

e oc

clud

ed b

y th

e cl

amp.

To p

reve

nt tr

aum

a to

the

intim

a of

the

vess

el

caus

ed b

y th

e cu

tting

edg

e of

the

need

le a

nd

to m

inim

ise

pain

.

Sta

ff/pa

tient

edu

catio

n an

d tra

inin

g.

11

12

Sect

ion

6

Patie

nt In

form

atio

n St

atem

ent

Rea

son

for s

tate

men

t H

ow is

it b

eing

ach

ieve

d

All

patie

nts

shou

ld b

e in

form

ed

abou

t sim

ple

emer

genc

y pr

oced

ures

and

how

to b

est c

are

for t

heir

dial

ysis

acc

ess.

Pat

ient

mus

t be

awar

e of

wha

t ac

tion

to ta

ke in

eve

nt o

f ha

emor

rhag

e.

Pat

ient

pla

ys a

n im

porta

nt ro

le in

th

e de

velo

pmen

t and

pr

eser

vatio

n of

the

fistu

la a

nd in

ea

rly d

etec

tion

of c

ompl

icat

ions

.

Com

plic

atio

ns m

ay in

clud

e th

e fo

llow

ing:

infe

ctio

n

haem

orrh

age

thro

mbo

sis

is

chae

mia

para

sthe

sia

(Ste

al

synd

rom

e)

Pat

ient

sho

uld

be p

rovi

ded

with

info

rmat

ion

rega

rdin

g th

eir a

cces

s si

te th

roug

h ea

sily

und

erst

ood

verb

al a

nd w

ritte

n co

mm

unic

atio

n.

A re

cord

is k

ept o

f inf

orm

atio

n gi

ven

to p

atie

nts.

12

13

Appendix 1 Vascular access creation – Pre-dialysis patients

(LA/GA - Day Cases)

FISTULA CREATION – CHECK LIST

Patient referred to vascular surgeon from low clearance clinic when creatinine: > 300 umol/l diabetic

> 400 umol/l non diabetic

Patient reviewed by vascular surgeon: • vascular access assessed • further investigations/tests

arranged

Surgeon’s secretary arranges admission list for access creation and informs: • day surgery unit (DSU) • anaesthetic secretary • renal unit sister • pre-dialysis nurse/vascular access nurse • pre-dialysis patients highlighted and LA/GA indicated

- LA/GA indicated

1. Pre-dialysis/vascular a nurse will: • contact patient to discuss admission details • arrange for patient to attend renal department (Fri) prior to theatre (Tues) for pre-theatre assessment

o Us and Es, bone profile, glucose and FBC o coagulation screen o MRSA screening o fluid assessment o medication check

• arrange a pre-operative visit to DSU • give stress ball & explain pre- and post-operative access care to patient • inform SHO of blood results and arrange for doctor’s assessment • arrange for anaesthetic assessment GA: 12 lead ECG, chest x-ray and review by anaesthetist

arm block: review by anaesthetist 2. SHO will:

• document patients blood results and general condition in case notes and act on results • arrange admission to ward if patients condition/blood results require • commence appropriate antiplatelet medication if admitted, ward staff will liaise with DSU – • if patient is diabetic and having a local anaesthetic, fasting is not required on morning of theatre - breakfast can be

taken as normal • anaesthetist will assess whether GA patients require to be admitted/fasted prior to theatre • if patient is well & blood results stable then patient can go home and attend DSU as previously arranged • vascular surgeon will gain consent from patient in DSU just prior to theatre

DSU will inform patient in writing re: admission details and provide any advice/instructions that are required (DSU Booklet sent out to patient).

1. Patient attends DSU for surgery. 2. Patient will be reviewed by vascular surgeon and anaesthetist post-operative (if required). 3. GA patients may be required to remain in DSU until early evening for post-operative observations. 4. Upon discharge DSU staff will provide patients with:

• guidelines for care of fistula – post-op & long term care • vascular out-patient clinic appointment for fistula review with vascular access surgeon 2-4 weeks post-op • emergency contact numbers • arrangements for district nurse to review wound 3 days post-operative.

5. Pre-dialysis nurse will follow patient up at home and at clinics.

Assessment letter/report sent to: • referring Physician • pre-dialysis nurse • vascular access nurse • RDU Sister

14

Appendix 1a

NAME _____________________ I.C No. ______________ D.O.B ___________ Pre-theatre check: Date ______________ Date of Surgery ______________ BP _______ T _______ Pulse _________ Wt _________ Pre-dialysis nurse

Y N Date Comments

Patient phoned and informed of theatre arrangements

Medical admissions informed Us and Es/FBC/bone profile /haematinics Coagulation screen MRSA screen Fluid assessment Medication check 12 lead ECG Chest x-ray Anaesthetist review SHO informed of blood results SHO assessed and documented patients condition

Patient allowed home Patient admitted to ward Case notes sent to DSU Admission details to DSU explained ‘Stress Ball’ given Day surgery unit

Care of fistula guidelines given Vascular out patient appointment arranged District nurse referral Pre-dialysis nurse informed of admission post-operative

Surgeon ____________________ Anaesthetist ______________________ SHO ___________________ Pre-dialysis nurse __________________ DSU nurse ____________________ Appendix 1a Example of fistula creation checklist (Crosshouse Hospital, Kilmarnock)

15

Appendix 2 Example of local protocol on post-operative care

Specific: Post-operative care of a patient following AVF formation and graft

insertion for access to haemodialysis.

1. Carry out all basic nursing care as for any patient following general anaesthetic. 2. Blood pressure and pulse recordings every 15 minutes for the first hour. Nurses

should be aware that there is an increased risk of the patient’s access clotting if their blood pressure drops:

• if satisfactory record observations every half hour for 2 hours • if patients observations are stable then 2-hourly recordings until discharge • if the patient’s blood pressure drops consult vascular surgeon.

3. Observe and record fistula bruit every 15 minutes for the first hour. Listen with a

stethoscope: • monitor bruit/thrill every half hour for a further 2 hours • monitor bruit/thrill every 2 hours until discharge • if the bruit/thrill is quieter/softer than before, contact vascular surgeon

immediately • surgeon or theatre nurse should pass information to the receiving nurse as to

how and where the bruit/thrill can be felt or heard. Some bruit/thrill may not be heard through the theatre dressing.

4. Observe wound for signs of bleeding every 15 minutes for 1 hour.

• then observe every half hour for 2 hours • then observe every 2 hours until patient is discharged • if evidence of bleeding consult vascular surgeon immediately.

5. Observe for signs of coldness or parasthesia in patient’s hand. Steal syndrome can be an early complication of AVF/graft formation. Consult vascular surgeon immediately.

6. Observe for signs of numbness (after the block has worn off) or extreme pain. 7. Give patient advice and education literature before discharge. Record that this has

been done.

Appendix 2 and 2a Example of local protocol on post-operative care (Queen Margaret Hospital, Dunfermline)

16

Appendix 2a NAME: UNIT NO: Date Commenced: Update N

o Actual/potential problems

Desired outcomes Nursing actions

2.

Care of newly formed fistula Type of formation:

AVF remains patent. Colour, sensation and movement maintained in limb below area where fistula was formed. Bruit maintained.

1. Patency of fistula is determined by following actions: a) fistula is checked ¼ hourly for first 2 hours, hourly for 6 hours, 2 hourly for 12 hours, 4 hourly for remainder of time in hospital. b) arm does not remain bent. c) no BP cuff is to be attached to arm where fistula has been created. d) no bloods to be taken from arm where fistula was created. e) patient advised against lying on appropriate arm. f) vital signs monitored regularly. 2. Observe colour, sensation and movement of limb regularly. 3. If any deterioration inform medical staff immediately. 4. Patient is given appropriate information / literature at all times.

Appendix 2 and 2a Example of local protocol on post-operative care (Queen Margaret Hospital, Dunfermline)

17

Appendix 3 Management of non-functioning vascular access

Appendix 4

Sudden onset of: • absent or reduced thrill/bruit • collapsing fistula • clot aspiration on initial puncture • high (negative) arterial pressure.

The need for dialysis may be greater than the need for surgery: • clinical assessment of fluid and electrolytes is essential • contact vascular surgeon • if required temporary line inserted.

Urgent angiographic assessment In areas where a 24 hour, 7 day interventional radiology cover is not available, patient should be managed in the renal unit or renal ward, and referred to interventional radiology as soon as it is available.

Lysis, if thrombosis is present.

Angioplasty, if stenosis is present.

Surgery, if ligation is necessary.

Fistula may be used immediately.

Consult with surgeon.

Fistula may be used immediately.

Consult with surgeon.

Refer for tunnelled central venous catheter as soon as

possible. Temporary line should be

used for 10-14 days.

if successful if successful if successful

• if the fistula is unsalvageable, arrangements should be made for tunnelled central venous catheter insertion.

• assessment for further vascular access should be made by vascular surgeon

All interventions should be recorded in patient’s case notes and communicated back to the renal unit charge nurse.

18

Appendix 4 Cannulation of new AVFs and grafts Purpose: To successfully cannulate new AVF and to prevent infiltration. Policy:

Newly created primary AVFs shall be allowed to develop for at least 8 to 12 weeks prior to cannulation. Initial attempts to perform dialysis via new fistulas shall proceed with caution. Without exception, fistulas shall not be progressed faster than these guidelines without consultation with vascular surgeon, vascular access nurse or nephrologist. All healthcare professionals are responsible for implementing this policy. Procedure: 1. Obtain order from vascular surgeon or nephrologist to begin cannulation of fistula 8

to 12 weeks after creation. All new fistulas should be examined by surgeon, nephrologist and designated staff member before cannulation is initiated.

2. Only staff identified as demonstrating best cannulation practice techniques should be assigned to cannulate newly developing fistulas.

3. Always use a tourniquet, even with well-developed fistulas. No exceptions.

4. Explain procedure to patient.

5. Educate patient on: • checking the access daily for a thrill and for signs and symptoms of infection • performing fistula exercises to promote maturation process • understanding that haematoma could occur most likely during the first two weeks

of using the access • for infiltrations, provide written materials about icing, elevation, and heat

application.

19

Types of cannulation techniques to use for AVF

Technique Advantages Disadvantages

Rope ladder Cannulate the entire length of the fistula, ensuring subsequent needle insertions are 2cm above the former cannulated site.

Prevent aneurysm formation.

If the AVF is small then it is difficult to move up and down sites. Often the same sites are cannulated.

Regional or area puncture (not advised).

To cannulate same or close to same area as before. One or two areas of the fistula are regularly used.

Less infiltration. Easy for staff to identify needle sites.

Thinning of skin causes increased bleeding time. Infection due to skin breakdown. Increased risk of aneurysms.

Buttonhole cannulation.

Create a track so blunt needles can eventually be used in order to facilitate dialysis.

Less infiltration. Less pain. Reduced bleeding times.

Same person needs to cannulate the AVF in order to ensure exact track formation. Takes time and 2 experienced nurses to develop track.

Cannulation of graft

Technique

Cannulation of grafts is very different to AVF. The graft is made of a synthetic material andIs tougher than native vessels.

Cannulate at a 45% angle, bevel up. Force the needle through the skin and graft and straighten the needle when flashback is seen.

20

Appendix 5 Blood flow rates (BFR) are recommendations and can be modified based on centre-specific guidelines. Only increase BFR if no evidence of infiltration or other problems noted. Report any cannulation or BFR problems to the charge nurse. Week two:

• if the first week is successful, cannulate with 16 gauge needles, rotating cannulation sites if not using buttonhole.

• blood flow rate recommended: 300 ml/min. Week three:

• either repeat procedure for week 2, or may attempt to progress to prescribed BFR and needle gauge. When increasing BFR, recommend matching needle gauge to BFR as shown in chart below,

• recommended needle placement: arterial retrograde (toward the arterial anastomosis), venous antegrade (toward the venous anastomosis). (this policy may vary based on policies and procedures of specific units)

Infiltration instructions

If the fistula infiltrates, let it “rest” for one week and then go back to smaller gauge needles. Notify charge nurse, vascular access nurse or nephrologist. If the fistula infiltrates a second time, wait another two weeks and then go back to smaller gauge needles. Notify charge nurse, vascular access nurse or nephrologist. If the fistula infiltrates a third time, notify surgeon and nephrologist.

RECOMMENDED: It is important to match needle gauge to blood flow rate. BLOOD RECOMMENDED FLOW RATE NEEDLE GAUGE

<300 ml/min

17-gauge

300 – 350 ml/min

16-gauge

>350-450 ml/min

15-gauge

> 450 ml/min

14-gauge

Note: These are minimum recommended gauges for the stated BFR settings. Larger needles, when feasible, will reduce (make less negative) pre-pump arterial pressure and increase delivered blood flow.

21

Appendix 6 Patient information - care of your fistula/graft Following Theatre: • for 24 hours following your anaesthetic it is important to adhere to the following

instructions: o do not drive o do not operate machinery, cookers or kettles o avoid alcohol and do not take sleeping tablets o do not make important decisions or sign legal documents

• if you feel any discomfort following surgery, painkillers may be taken as prescribed –

paracetamol/panadol

• you may be given some medication that helps to prevent your fistula/graft from clotting, it is very important that you take this medication as prescribed

• if any bleeding occurs, apply pressure with a clean cloth. If bleeding continues beyond 15 minutes, contact the Ward or attend your nearest A&E department

• your top theatre bandage can be removed 24-hours following surgery leaving a small white dressing over your wound

• keep this dressing clean and dry. If it gets wet or dirty please contact the pre-dialysis nurse.

• following surgery it is very important that you check your fistula/graft twice daily. This is done by placing your other hand gently on top of the dressing to feel a slight buzzing sensation. This means that your fistula/graft is working properly. If you do not feel this please contact the ward, pre-dialysis nurse or vascular access nurse for advice immediately.

• a district nurse will visit and assess your wound 3 days after surgery

• your stitches are self-dissolving, therefore do not need to be removed

• observe your wound regularly for any signs of redness, swelling or leakage

• ensure hands are washed prior to touching your fistula/graft wound

• once your dressing is removed you may bath/shower as normal, avoid using soap or talcum powder over the wound until the wound is completely healed

• you will be required to attend an outpatient clinic 2-4 weeks following surgery just to ensure there are no problems with your fistula/graft. You will receive an appointment through the post following discharge from the DSU.

• gentle hand exercises may be commenced once all dressings have been removed. These will help strengthen and build up the vein in your fistula/graft. Commence by squeezing your stress ball gently for several minutes 2-3 times/day. Increase the frequency of these exercises over the next few weeks.

22

Glossary Term

Definition

adequacy Refers to how well dialysis replaces the function of the kidneys.

anastomosis

An artificial connection between two tubular organs eg two blood vessels.

arterio-venous fistula

A surgical connection between an artery and a vein, usually in a limb, to create arterial and venous access for haemodialysis. It can be a direct anastomosis between the artery and vein.

asepsis

The complete absence of bacteria, fungi, viruses or other micro-organisms that could cause disease.

autogenous

Originating in the body of the patient.

bruit

A sharp or harsh systolic sound heard on auscultation that is due to turbulent blood flow in a peripheral artery. Bruits can be heard over arterio-venous fistulae.

cannula

A hollow tube designed for insertion into a body cavity or blood vessel.

cannulation

Insertion of a cannula.

co-morbidity

The presence of one or more disorder or disease in addition to the primary disease.

DOQI The national kidney foundation Dialysis Outcomes Quality Initiative. Established in 1995 in the USA.

duplex imaging A diagnostic technique used to study the flow in blood vessels.

end stage renal failure (ESRF) The most advanced stage of kidney failure, which is reached when the glomerular filtrate rate falls to 5mls/min (normal GFR =120ml/min).

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extravasation The leakage and spread of blood or fluid

from vessels into the surrounding tissues eg following injury.

glomerular filtration rate (GFR) The rate at which substances are filtered from the blood of the glomerulus into the bowman’s capsule of the nephron. It is calculated by measuring the clearance of specific substances and is an index of renal function.

haematoma An accumulation of blood within the tissues that clots to form a solid swelling.

haemodialysis A technique of removing waste materials or poisons from the blood using the principle of dialysis. Haemodialysis is performed on patients whose kidneys have ceased to function.

heparin An anticoagulant which acts by inhibiting the action of the enzyme thrombin in the final stage of blood coagulation.

infiltration The abnormal entry of a substance into tissue eg blood.

intima

The inner layer of a wall of an artery or vein.

patency The condition of being open eg blood flow present.

protocol Correct procedure (should be evidence-based).

thrombosed Affected by thrombosis.

thrombosis

A condition in which the blood changes from a liquid to a solid state and produces a blood clot.

tourniquet

An instrument for the compression of a blood vessel by application around an extremity to control the circulation and prevent the flow of blood to or from the area.

venepuncture

The puncture of a vein for any therapeutic purpose.

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References

Beathard G A (1992) Physical Examination of AV Grafts Sem Dialysis 5 74

Beathard G A (2002) Improving Dialysis Vascular Access Dialysis and Transplantation 31: 4 pp 210-217.

Brouwer D, Peterson P (2002) The arteriovenous graft: How to use it effectively in the dialysis unit Nephrology News and Issues Nov 2002: pp 41-49.

Brunori G, 2005 Fistula maturation, doesn’t time matter at all? NDT. April, 20(4) pp 684-687

Fistula First National Vascular Access Improvement Initiative (2003) A practitioners resource guide to Physical Examination of Dialysis Vascular Access. Available at: http://www.esrdnetwork.org/fistula_first_qip.htm#pe

Konner K, Nonnast-Daniel & Ritz E (2003) The Arteriovenous Fistula Journal of the American Society of Nephrology 14: 1669-1680.

Merrill D, Brouwer D, Briones P (2005) Haemodialysis Access: A guide for caregivers and patients. Dialysis and Transplantation. 34:4; 200-206.

National Kidney Foundation K/DOQI Clinical Practice Guidelines for vascular Access 2000 (2001) American Journal Kidney Diseases 37:S137-S181 (supplement 1).

Vanholder R (2001) Vascular Access: care and monitoring of function Nephrology Dialysis Transplantation 16: 1542-1545. Rayner, H 2003 Creation, cannulation and survival of arterio-venous fistulae: Data from the Dialysis Outcomes and Practice Study. Kidney International. Jan, 63(1) pp 325-330.

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Who was involved in developing the statement? Working group members Carol Latta Ward Manager, RDU Gartnavel General Hospital, NHS

Greater Glasgow

Caroline Arnott Ward Manager, Renal Unit, Queen Margaret Hospital, Dunfermline

Anne Allan Clinical Ward Manager, Renal Unit Raigmore Hospital, Inverness

Anne Petherick Education Co-ordinator, Renal Unit, Edinburgh Royal Infirmary

Barbara Killoran Lecturer, Adult Nursing, University of Paisley, Paisley

Geraldine Ovens Renal Education Facilitator, Renal Unit, NHS Ayrshire & Arran

Ippy Brown Clinical Nurse Manager, Renal Unit, NHS Greater Glasgow

Julie English Clinical Educator, Renal Unit, Raigmore Hospital, Inverness

Laurie Kirkland Pre-dialysis Nurse, NHS Ayrshire & Arran

Margaret Boyd Clinical Facilitator, Renal Unit, Monklands General Hospital

Morag McGhee Clinical Nurse Manager, Renal Unit, Monklands General Hospital

Noreen McMahon Ward Manager, Crosshouse Hospital, Kilmarnock

Rhona Lochiela Vascular Access Nurse, Edinburgh Royal Infirmary

Temby Chigaru Clinical Educator, Queen Margaret Hospital, Dunfermline

Sean McCartney Senior Charge Nurse, Renal Unit, Ninewells Hospital, Dundee

Jacqueline Ross Acting Ward Manager, Renal Unit, Aberdeen Royal Infirmary

Jacqueline Annand Senior Staff Nurse, Renal Unit, Aberdeen Royal Infirmary

Jane Rodriguez Ward Manager Renal Unit, Falkirk Royal Infirmary

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Wider reference group Sister Aileen Heminglsey HD sister Monklands Hospital, Airdrie Dr W Smith Consultant Monklands Hospital, Airdrie Dr M Hand Consultant Monklands Hospital, Airdrie Dr I Shilliday Consultant Monklands Hospital, Airdrie Dr H Oun Associate Specialist Monklands Hospital, Airdrie Dr M McGregor Consultant Crosshouse Hospital Kilmarnock Dr K Simpson Consultant Glasgow Royal Infirmary Dr C Brunton Consultant Aberdeen Royal Infirmary,

Aberdeen Dr A Severn Consultant Ninewells Hospital Dundee Dr R Peel Consultant Raigmore Hospital, Inverness Dr S Lambie Consultant Raigmore Hospital, Inverness Dr M Wood Consultant Queen Margaret Hospital, Dunfermline Dr K McBride Consultant Queen Margaret Hospital, Dunfermline Dr S Rodger Consultant Western Infirmary, Glasgow Ms L Buist Consultant Western Infirmary, Glasgow Ms Alison Wilkinson Patient Representative Ninewells Hospital, Dundee