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Reprinted with permission from Dialysis & Transplantation, Vol. 24, No. 11, 1995.

Deborah J. Brouwer, RN, CNN

Cannulation Camp:
Basic Needle
Cannulation Training
for Dialysis Staff
This article reviews the basic skills needed by all dialysis staff to correctly cannulate an AV
fistula or PTFE graft. Ways to identify the two types of accesses and to determine the
direction of bloodflow are described. Access site determination and preparation, needle
placement and direction, and various cannulation techniques are explained and supported by
illustrations. Complications are examined, as are possible treatments and ways to prevent
recurrences.

H
ow did you learn to cannulate a The flow direction of either a fistula or
dialysis access? Most practicing graft must be correctly identified in order to
nephrology nurses and techni- ensure proper needle cannulation. Most
cians - myself included - had on-the-job fistulas flow from the distal end of the limb
training. We observed our preceptor toward the venous return. The direction of
cannulate different patients who had either flow of a particular fistula can be easily
grafts or fistulas, and then were handed identified by locating the arterial
the needles for our first cannulation anastomosis engorgement prior to
attempt. placement of a tourniquet. Another method
Very little nursing research and/or is to listen for the bruit and feel for the
literature is available for a preceptor to use thrill, which should be noticeably stronger
when teaching the art of needle at the arterial end of the fistula.
cannulation. The purpose of this article is
to provide current nephrology staff with a
basic knowledge of needle cannulation,
information which may then be passed on
to new staff entering the nephrology field.

Step I: Identify the Type


of Access and Direction
of Bloodflow
The preferred dialysis access is the
arteriovenous (AV) fistula. This is due to its
high patency rate and the strong ability of
The illustrations for this the puncture sites to heal. However, due to
article were provided by vascular limitations, only about 30% of all
W.L. Gore & Associates, Inc. dialysis patients have working AV fistulas.1
The majority of the The most common AV fistula is one
illustrations were adapted
with permission from the
connecting the radial artery to the cephalic
Gore publication, Vascular vein, created at the patient's wrist. A fistula
Access for Hemodialysis-IV. can also be created in the upper arm,
connecting the brachial artery with the
axillary vein or another upper arm vein, all
Deborah Brouwer is of which lead to the subclavian vein. A leg
with Dialysis Clinic, Inc., fistula can also be created in patients with
Pittsburgh, Pennsylvania limited access options. Figure 1. Regular or “blue thumb” graft.
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Cannulation Camp
Unfortunately, the flow direction stronger bruit and thrill can be
within an implanted polytetrafluo- considered to be the arterial limb.
roethylene (PTFE) graft cannot be Next, the graft can be
so easily identified. This is because cannulated with two needles and
a graft can be placed in any the blood flashback observed.
location where an artery and vein When the mid-graft area is
can be connected. The traditional compressed, the arterial needle
graft sites - i.e., the lower arm (loop flashback should remain visible,
graft) and upper arm (straight graft) while the venous needle flashback
- have now been supplemented by should greatly diminish or
straight or loop grafts in the leg, disappear.
groin, abdomen, chest, or neck. As If a graft is to be used prior to
such, the direction of the bloodflow the clearance of all residual
may not be apparent by visual operative edema, it may be difficult
inspection alone. to palpate the graft or to compress
Cooperation with the vascular the mid-graft segment in order to
surgeon in obtaining a drawing or show a difference in blood
Figure 3. Direction of bloodflow
description of the bloodflow flashback within the arterial and determines needle placement.
direction is the best way to ensure venous needles. In this case,
proper use of the access. In the noting the venous pressure and with the flow direction. In this
absence of such records, several pre-pump arterial pressure may regard, grafts can be described as
techniques can be used to assist in determining the bloodflow being either a regular or "blue
determine bloodflow direction. As direction. To accomplish this, the thumb" graft, or a reverse or "red
previously mentioned, the most needles are connected to the thumb" graft. A "blue thumb" graft
commonly used technique is to dialysis circuit, a 200 ml/min blood- is when the arterial inflow is on the
listen to the bruit and feel for the flow is achieved, and the mid-graft limb of the graft medial to the
thrill at both ends of the graft; the region is lightly compressed. If the midline of the body or heart (see
end with the stronger bruit and thrill needles have been correctly Figure 1). A reverse or "red thumb"
is assumed to be the arterial limb. connected arterial-to-arterial and graft is one in which the arterial
To confirm this assumption, the venous-to-venous, the venous inflow is on the limb of the graft
mid-graft area can be lightly pressure will fall due to the distal to the body midline or heart2
compressed to impede the decrease in bloodflow to the (see Figure 2). Of all dialysis loop
bloodflow; again, the end with the venous limb when the mid-graft grafts, approximately 80% are
region is compressed. If the arterial regular, with the remaining 20%
bloodline has been incorrectly being reverse.3 The red or blue
connected to the needle in the thumb concept can be easily taught
venous limb of the graft and the to patients so that they may
venous bloodline to the needle in understand the bloodflow direction
the arterial limb, the pre-pump within their own access.
arterial pressure will change to a
more negative number and the
venous pressure will increase. This
is a result of the mid-graft
compression causing the arterial
bloodline connected to the venous
limb of the graft to work harder in
order to receive the inflowing blood;
the venous pressure increases due
to the compression of the venous
outflow track. If this occurs, the
bloodlines should be reversed, the
mid-graft compression repeated,
and a fall in the venous pressure
should then be observed.2
Once the direction of the Figure 4. Venous needle always points
bloodflow is determined, the toward the venous return. Arterial needle
Figure 2. Reversed or “red thumb” graft. patient's chart should be marked may point in either direction.

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Cannulation Camp
placed in the same direction on the
same limb, for if they are placed
too close, such as less than 3"
apart as measured from hub to
hub, the needle bevels may touch
or be too close and lead to
recirculation2 (see Figure 7).
Both antegrade and retrograde
cannulation can be used with AV
fistulas, as well. Antegrade cann- The needle sites selected for
ulation can be used to cannulate cannulation must be properly
Figure 5. Needle placement if only one near the arterial anastomosis of an prepped in order to prevent
portion of the graft can be used for access without the needles enter- infection. Proper washing of the
cannulation. ing the anastomosis site. This is patient's access area with water
Step II: Needle Site particularly helpful with newly and an antibacterial soap should be
created AV fistulas that are not fully done prior to cannulation. If the
Selection
matured, as the antegrade patient is unable to wash his or her
Since the placement and direction
cannulation can sometimes provide own access area, the dialysis staff
of the access needles can vary,
a higher bloodflow with less can use a washcloth soaked with
needle site selection should be
bloodline collapse or line sucking, antibacterial soap to cleanse the
determined before skin preparation
and a better pre-pump arterial area. A ready-to-use antibacterial
and needle cannulation are per-
pressure. towel or prep pad can also be
formed.
Needle site placement must used.
It is the direction of the
always take into account needle After cleansing, the sites
bloodflow that determines the
site rotation. This is true for both should then be prepped with either
needle placement. This is because
AV fistulas and grafts. Proper Betadine or alcohol. Once applied,
the venous needle must always
needle site rotation will extend the Betadine must be allowed to dry
point toward the venous return. The
life span of the access by before it is an effective antiseptic,
arterial needle, on the other hand,
preventing pseudoaneurysm form- whereas alcohol must be used in a
may point in either direction (see
ation, or "one-site-itis" (see Figures liquid state to be effective.5 During
Figures 3 and 4).
8 and 9). Additionally, fistulas that the preparation of the access sites,
The terms antegrade and
are cannulated throughout the universal precautions, including the
retrograde are used to describe the
entire fistula will mature more wearing of gloves, must always be
direction of the arterial needle.
evenly, and grafts so cannulated used to prevent the spread of
Antegrade cannulation has the
will not develop flat, mushy areas infection.
arterial needle pointing in the
caused by repeated cannulation in
direction of the bloodflow, that is,
the same spots, which do not allow Step IV: Local Anesthesia
toward the venous limb. Retro-
for fibrous tissue formation and, If the patient experiences
grade cannulation has the arterial
subsequently, lead to the develop- discomfort during cannulation, the
needle pointing toward the arterial
ment of large holes (Figure 9). administration of an intradermal
anastomosis.4 Either of these cann-
A patient record of the cann- injection of lidocaine may be used
ulation techniques can be used,
ulation sites-such as an illustrated immediately prior to the needle
with the choice being based on unit
bedside cannulation chart and a cannulation. Other agents, such as
practice.
cannulation rating chart-can be Chloroethane (ethyl chloride)
When complications such as
used to help ensure full needle site spray, or lidocaine 2.5% with
infection or recent surgical revision
rotation (see Figures 10 and 11). prilocaine 2.5% (Emla Cream), can
dictate that only one limb of a loop
graft can be used, the needles may also be used to prevent discomfort
be placed on the same side of the Step III: Skin Preparation from the cannulation. Because of
graft, with one needle placed the potential for further discomfort
upward and the other downward, brought on by additional needle
as shown in Figure 5. When that is sticks, the choice of using lidocaine
the case, the needles must always as a local anesthetic for needle
be at least 1" apart, as measured cannulation should be at the
from hub to hub, in order to prevent request of the patient; however, its
recirculation (see Figure 6). use should be avoided in the case
Care should be taken in those of a deep or edematous graft-which
cases where the needles are may occur with newly created
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Cannulation Camp
skin, which facilitates cannulation
through the skin, subcutaneous
tissue, and the graft wall or fistula
vessel wall.
The needle should be held at a
20- to 35-degree angle for AV
fistulas, and at approximately a 45-
degree angle for grafts.6 Once the
needle has been advanced through
the skin, subcutaneous tissue, and
graft or fistula wall, the blood
flashback should be visible.
Continue to advance the needle no
greater than 1/8 of an inch and
then rotate the needle 180
Figure 8. “One-site-itis” due to repeated needle puncture in the same location, degrees6 (see Figure 13). The
the result of poor needle site rotation. needle bevel is rotated to help
prevent a "back wall" or posterior
PTFE grafts-where the injection of to 500 ml/min are now standard in wall infiltration, which can occur if
lidocaine prevents palpation and many dialysis units). the needle's bevel tip accidentally
easy cannulation. Pre-pump arterial pressure punctures the bottom of the graft or
When using lidocaine, the monitoring can help determine if fistula (see the discussion under
minimal amount (0.2 cc) should be the needle gauge needs to be "Cannulation Problem-Solving").
used, and the patient should be increased. If the arterial pressure The needle should then be
warned that the injection might falls lower than -200 to -250 leveled out (i.e., placed flat against
burn or sting. Care must always be mmHg, the needle size should be the skin) and then advanced slowly
taken to ensure that the lidocaine is increased (i.e., a smaller gauge up to the needle hub (see Figure
injected only into the tissue on top number should be used). However, 14).
of the access and never into the this decision should first be
graft or fistula itself. discussed with the dialysis staff Step VII: Securing
and the nephrologist. the Needle
Step V: Needle Selection The wings of the fistula needle can
The specific gauge of the needles Step VI: Cannulation be secured by using a butterfly
used for cannulation should always Technique tape technique. A piece of 1"-wide
be ordered by the nephrologist in The needle should be held by the adhesive tape 6" or greater in
order to ensure that an adequate wings, with the bevel of the needle length is carefully placed under the
bloodflow rate is achieved for the facing upward for the cannulation fistula needle wings and then
proper delivery of the dialysis (see Figure 12). This places the folded so that it crosses over the or
prescription. The length of the cutting edge of the needle on the
needles, on the other hand, may be
altered by the dialysis staff in order
to reach, for instance, deep grafts
such as those found in the upper
arm of an obese patient, where a 1"
needle may not be long enough to
cannulate the graft or advance far
enough into the graft to prevent
movement. In that case, a 1 1/4"
needle may be helpful.
The needles used should
always have a back eye to ensure
that the optimal flow is achieved.
Additionally, the standard 16-gauge
needle may need to be increased
to a 15- or 14-gauge in order to
achieve bloodflows greater than
300 ml/min (bloodflow rates of 350 Figure 9. A pseudoaneurysm caused by “one-site-itis,” which can lead to graft failure.

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Cannulation Camp
procedure, a 2x2 vessel, as this could cause further
gauze pad may be damage to the vessel wall.
placed under the Should an infiltration occur,
needle wings to cannulation with another needle
correct the needle should be performed at a spot as
angle. Care must far away from the infiltration site as
be taken with any possible. If the infiltration has been
change to the caused by a venous needle, the
needle position so second needle should be placed
that infiltration into above the infiltration site. However,
the back or side this is not always possible, and if
wall of the graft or the venous needle must be placed
fistula is avoided. below the infiltration site, it should
be placed 1 1/2" to 2" away from
the site to prevent the needle tip
Step VIII:
from dislodging the clot formation
Cannulation at the site of the vessel wall
Problem- infiltration. Following the second
Solving cannulation, careful flushing of the
Figure 10. Bedside cannulation chart, showing dates and
If resistance is felt venous needle, along with a slow
locations of prior puncture sites.
at any time during restart of the dialysis blood pump,
needle site. An adhesive bandage needle advance-ment or needle should be performed in order to
or a 2x2 gauze pad is then placed position change, the needle should monitor the infiltration site for an
over the needle and secured by be pulled back and the angle increase in hematoma size.
another 6"-long piece of tape. redirected. When in doubt, always Care must be taken with all
The needles must be secured ask a colleague for help. needle cannulations in order to
in place in order to prevent A back or side wall infiltration prevent infiltrations. A severe
accidental dislodgment or move- can occur with any needle infiltration, such as a posterior or
ment of the needles within the cannulation. If an infiltration does back wall infiltration in a PTFE
access, and care must be taken to occur prior to the patient receiving graft, can lead to the formation of a
monitor the needles for inadvertent heparin, the needle should be large hematoma and subsequent
movement during the dialysis pulled out and digital pressure graft compression and/or graft
treatment. This movement within applied to the exit site by placing thrombosis. While the use of the
the graft or fistula can result from two fingers along the access- 180-degree needle rotation, or
the patient rotating or bending his extending over a minimum of a 1" "flip," discussed earlier is not
or her access limb, which may lead span-in the area of the infiltration. necessary to correctly cannulate a
to poor bloodflow and/or needle Unfortunately, it is difficult to control PTFE graft or fistula, it may help
infiltration. back or side wall bleeding because decrease the chance of a severe
Special care must be taken direct pressure to the puncture site infiltration. When training new staff,
with deep or edematous grafts is not possible.
because the needles are more If the patient has already
prone to shift after the cannulation. received heparin, the infiltration site
With edematous grafts, this results must be carefully assessed to see
from the edema being displaced if the needle should be pulled out
following the application of or left in place with ice applied over
pressure during the palpation and the site until the dialysis treatment
cannulation of the graft, with the is completed. If the infiltration site
edema subsequently returning to remains stable with no increase in
the subcutaneous tissue surr- the size of the hematoma, the
ounding the cannulation sites and needle can be safely left in place
causing the movement of the and pulled out at the end of the
needles. With deep grafts, move- treatment. If, however, the
ment can occur simply because of hematoma increases in size, the
the amount of tissue pressing needle should be removed and
against the needle. digital pressure applied. Never
Should any movement of the apply pressure to an infiltration site
needles occur during the dialysis while the needle is still in the

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Cannulation Camp
this technique may be particularly movement of the needles. Each that bloodflow occlusion (which
helpful in preventing the staff needle is then withdrawn slowly, at could possibly cause thrombosis of
member from advancing the needle a 20-degree angle, until the entire the access) has been averted. A
into and through the vessel in one needle has been removed. To family member can be trained to
smooth, uncontrolled movement. prevent damage to the vessel wall, assist patients who are unable to
In a recent article by Hartigan,4 digital pressure should not be maintain compression of their own
the question is raised as to whether applied during needle removal.6 If needle sites.
flipping the needle may, in fact, the needle bevel has been rotated
actually cause additional trauma to 180 degrees during insertion, there
the intimal of the access. However, is no clinical evidence or research
Hartigan acknowledges that no that supports the re-flip or re-
controlled studies have been rotation of the needle before it is
performed to address the risks and withdrawn.
benefits of flipping or not flipping Once the needle has been
the needle during cannulation. removed, mild digital pressure
Dialysis staff, therefore, should should be applied to the needle exit
evaluate the infiltration problems sites of both the skin and graft or
that occur within their own practice vessel wall (see Figure 15). A
and appropriately adjust cannu- gauze pad should be held over the
lation techniques in order to sites with constant pressure,
decrease the number of infil- without peeking, for 10 to 15 When using topical clotting
trations. minutes. To ensure that both the agents, care must be taken to
skin and vessel needle exit sites ensure that the cannulation site has
Step IX: Removal are being compressed, the patient clotted and not just the needle exit
of the Needles should place both the index and site of the skin, for if hemostasis is
Proper needle removal is as middle fingers over the gauze pad, not achieved, blood may leak out
important as is proper needle with the thumb wrapped around the into the subcutaneous tissue
cannulation, for if the needles are limb like a "C" clamp. This will keep surrounding the graft. This often
improperly removed, damage to the the patient from shifting the happens when the patient stands
vessel wall can occur, whether with compression off of the exit sites, up to exit the dialysis unit, at which
PTFE grafts or AV fistulas. which would permit bleeding. The time the cannulation site can begin
The tape should be carefully bruit and thrill should continue to be re-bleeding if the clot over the skin
removed post-dialysis to prevent discernible above and below the puncture site is dislodged. If re-
compression sites, an indication bleeding is not visible from the skin
puncture site but has occurred
subcutaneously, ecchymotic areas
will be present when the patient
returns for his or her next dialysis
treatment.

Step X: Discharge Dressing


and Assessment
Always discharge the patient from
the unit with an adhesive bandage
or gauze pad over the cannulation
sites. Tape may be used to secure
the pad but should not be so tight
that it compresses the lumen of the
access.
Before the patient leaves the
unit, assess and document the
quality of the bruit and thrill. If the
bruit or thrill is greatly decreased or
absent, the patient must not be
discharged until the nephrologist
has been notified. And remember,
a Doppler-positive bruit does not
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Cannulation Camp
always equate with a positive bruit
and thrill.

CONCLUSION
Nursing research is needed to
better evaluate all cannulation
procedures. Our goal should be to
safely cannulate any access
without causing unnecessary
damage to the patient's lifeline. As
such, the basics of needle
cannulation must be openly
discussed among all patient care
staff members. We must work
toward having all dialysis staff
members understand and master
the basics of vascular access.
The fundamental principles
of vascular access should be used
to help train future dialysis staff
members in order to improve the
quality of care that future dialysis
patients will receive. We must
continue to gain knowledge in this
important area through nursing
research and education.

References
1. Fan PY, Schwab S. Vascular access:
Concepts for the 1990s. J Am Soc Nephrol
3:1, 1992.
2. Brouwer D. Hemodialysis: A Nursing
Perspective. In: Vascular Access for
Hemodialysis - IV (a W.L. Gore publication).
Henry M, Ferguson R (eds.). Chicago, IL:
W.L. Gore & Associates, Inc., and Precept
Press, 1992.
3. Raja RM. Vascular access for
hemodialysis. In: Handbook of Dialysis.
Daugirdas JT, Ing TS (eds.). Boston, MA:
Little, Brown & Co., 1994.
4. Hartigan M. Vascular access and
nephrology nursing practice: Existing views
and rationales for change. Advances in
Renal Replacement Therapy 1(2):156-157,
1994.
5. Perkins JJ. Principles and Methods of
Sterilization in Health Sciences (2nd Ed.).
Springfield, IL: Charles C. Thomas
Publishers. pp. 337-338, 1969.
6. Lancaster LE. Core Curriculum of
Nephrology Nursing. Pitman, NJ: American
Nephrology Nurses' Association, pp. 266,
272, 1995

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