ESRD Network 1
October 11, 2007
AV Fistulae:
Creation thru
Decades-long
Performance!
Janet Holland, RN, CNN
Director, DaVita Vascular Access
Management
“AV
Fistulae Babes or Dudes”
Performance Contest!
[email protected]
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Objectives
Participants will be able to:
9List assessment criteria of AV Fistula
Maturation & Cannulation readiness
9Describe Best Care Practices for
AV Fistula Performance
9Outline early indicators of AV Fistula
complications
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Why Focus on AV Fistulae?
• Patients’ own vessels (all natural)
• Most Likely to:
• Last Years/ Decades
• Remain infection-free!
• Maintain Access Blood Flow &
• not Clot!
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Care of AV Fistulae
Protect AV Fistula:
• Keep AV Fistula:
• Clean & Infection-Free:
• Wash and “pat dry” entire
access extremity pre-dialysis
• Wash hands pre & post dialysis
• Wear Clean Glove(s) to
“hold needle sites”
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Care of AV Fistulae
• Protect AV Fistula:
• Avoid Access Extremity Trauma:
Assure:
• Needles inserted smoothly
• Fully distended vessel (tourniquet)
• Removed @ insertion angle
• Post-dialysis hemostasis:
bleeding stops at
vessel & skin levels
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Care of AV Fistulae
• Protect AV Fistula:
• Avoid Access Extremity Trauma:
Avoid:
• clamps/ taping around access
• lifting/carrying heavy items
• tight jewelry, watches, etc
• lying/ sleeping on Access
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Assessment: Physical Exam
• Quick, easy to learn, cost effective
• Routine exam <1minute to perform.
• Provides “key-information” regarding
Vascular Access function
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Assessment: Physical Exam
• Vascular Access function
• Perform exam systematically
• Develop skills: Important Findings
• Think:
“Inflow”
“Access Flow”
“Outflow”
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Assessment Technique Best Tools?
Physical Exam!
Look, Listen and Feel—
Use Our:
Eyes
Ears
Fingertips
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“Look for Problems”
Compare Extremities
9Access versus Non-Access
9Edema (stenosis)
9Strength (steal)
Color change
9Warmth = possible infection
9Cold = decreased blood supply (stenosis)
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Patient Assessment
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“Look for Problems”
Access itself
9Observe from anastomosis all along
Fistula
9ID Narrowed or Distended areas
9Change(s) seen at the site of
stenosis
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Patient Assessment
Raise Access Extremity
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Care of AV Fistulae
Observe AV Fistula for Problems:
Use Dr Spergel’s Acronym: “BESTIPS”
Bleeding
Erosion
Stenosis
Thrombosis
Infection
Pseudo-Aneurysms/ Aneurysms
Steal Syndrome
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“Listen for Problems”
To the Patient
9Access
9concerns
9Pain
9Difficulties
Bruit
(hear Systolic and Diastolic)
9 Listen from anastomosis along fistula
9 Diminish evenly along access length?
9 Change(s) heard at the site of a stenosis
9 “Pulse-like” at the site of stenosis
9 Stenosis may be heard as a “high pitched sound”
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“Feel for Problems”
Compare Extremities
9Access versus Non-Access
9Edema
9Strength
Temperature change
9Warmth = possible infection
9Cold = decreased blood supply
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“Feel for Problems”
Thrill (feel Systolic and Diastolic)
9Palpate from anastomosis
along fistula
9Diminish evenly along access?
9Change(s) felt at the site of a stenosis;
9“Pulse-like” at the site of stenosis
9Stenosis may be identified as a “narrowed
area”
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Is New AVF Mature?
Use 2006 KDOQI “RULE of 6’s”
Depth below skin
< Approximately
0.6 CM
• 2006 KDOQI Vascular
Access Guideline
6 - 8 week Post Op • A Measurable tool to
Check AVF Maturation
“ Rule of 6’s ”
Diameter
Greater than
Access Blood Flow
Greater than
0.6 CM
600 mL/Min
Assess maturation
• Vein MUST Mature
Prior to the First
cannulation
• For all New AVF’s prior
to cannulation
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Is New AVF Mature?
Communicate new concepts:
• AV Fistula “Maturation” is?
• Less than 6 mm below skin
• Lumen Diameter >6 mm
• Vein Wall Thickness increased:
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Is New AVF Mature?
9Sufficient Arterial inflow(>600ml) is
Required
9Blood Flow not diverted to Side
Vessels
9No Stenotic areas diminishing flow
9J.A.S. Most Common cause of Early
AV Fistula Failure
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Complex AV Fistulae
• “New vessels” utilized:
• “Deep” Vessels
• Transpositions
• Vein surgically placed from
“normal” space to less than 0.6cm
(6mm) of the skin
• Using less commonly utilized
vessels
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Proximal radial artery AVF
Cephalic v.
Deep communicating V.
Basilic v.
Median antibrach. V.
Radial art.
Hand
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Cephalic v.
Med. Antibrach. V.
PRA-AVF
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AV Fistulae Maturation
9 Does Exercise help AVF Development?
9 Recent Research: Says, Yes, Maybe!
9 ASAIO Feb 2003
9 American Journal of
Medical Sciences 2003
Nothing replaces 24/7 arterial inflow
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AVF is Not Maturing
What is the Plan?
9“Just say No”… Do Not Cannulate
9Very common “New AVF” require minor
procedures to improve development
(70% of failing “New AVF” have JAS)
9Interventionalist may dilate stenotic areas
Or
9Surgeon may revise anastomosis…
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Superficialization & Straightening of
Brachiocephalic AVF
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AVF is Not Maturing
What is the Plan?
9 Follow-up Post Referrals:
9Did the Patient Go?
9What was done?
9 Is the AV Fistula now Maturing?
Communicate,
Communicate,
Communicate=
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AV Fistulae Maturation
9Adequate vessel enlargement 6 weeks?
(YES)
9AVF mature enough to cannulate? (YES)
9Time is not the only factor and more time
may not help
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KDOQI, CMS Fistula First,
Literature, Research Evidence:
• Experienced Dialysis Nurses
correctly assess Fistula >80%
(DOPPS)
• ONLY “EXPERT” cannulators to
cannulate New AV Fistulae
(KDOQI)
• Provide “New AVF” procedures and
cannulation training
(CMS FF)
• Education, Education, Education
(CMS FF)
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Cannulation Site Selection
• Site by inspection (area puncture):
Punctures in a couple of small areas
• Rope ladder (site rotation): Equal
distribution of punctures along the
length of the access
• Constant site (buttonhole): Repeated
Punctures at exactly the same 2-4 sites
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Cannulation Techniques
Kronung, Dial & Trans, 1984
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Area Punctures
• Easy puncture
• Tends to produce alternating areas of
aneurysm and stenosis
• Limits life expectancy of access
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Distal forearm radiocephalic AVF
Brachiocephalic AVF
Transposed basilic
vein AVF 33
Limited Access Ideal for Buttonhole
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Constant Site
• Infection not a significant problem when
protocol followed
• Decreased incidence of aneurysm and stenosis
• Allows use of limited length of AVF
• May need 3 or 4 constant sites to allow for
healing between cannulations, especially with
daily dialysis patients
• Variable amount of pain reported with
puncture but generally less than site rotation
technique
• Consistent, quick cannulation with only 1%
miss rate
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Buttonhole Tract
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In Conclusion:
Please Review with your Teams:
9Assessment criteria of AV Fistula
Maturation & Cannulation readiness
9Best Care Practices for Long-term
AV Fistula Performance
9Recognize early indicators of AV Fistula
complications
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In Conclusion:
Facility staff & nephrology team
members are vital to long term success
of the access.
Physical exam and skilled cannulation
techniques are critically essential
components of Vascular Access care.
care
“…we often ignore an effective technique that is literally
at the tip of our fingers. The patient’s access has a lot
to say if we will but listen.” Gerald Beathard
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