2. Cannulation Approach:
•For each hemodialysis treatment, the access
is cannulated usually with two needles.
•First, the arterial needle, allows the blood to
be withdraw from the patient into the dialysis
circuit .
•Second, venous needle, it will return the
purified blood back to the patient.
3. Cannulation Techniques
•There are 3 types of cannulation
techniques:
1.Rope ladder technique
2.Buttonhole technique
3.Area puncture technique
4. Area cannulation
technique
•refers to puncturing of the
same general area, session
after session
•But the repeated needle
puncture in the same area
weakens vessel walls and
predisposes the access to
the development of
aneurysms and access
stenosis.
5. Rope ladder technique
•The technician
changes the needle
placement sites for
each dialysis session,
choosing sites at a
defined distance
along a line from the
previous puncture
sites.
6. Buttonhole technique
•This is a method in which
an individual cannulates
the AV fistula in the exact
same spot, at the same
angle and depth of
penetration every time.
7. Physical Assessment of AVF before every
cannulation
•Compare arms for changes in skin colour, circulation,
integrity Inspect
•Access extremity for central or outflow vein stenosis
•Temperature change may mean infection or stenosis
•Change in thrill may mean stenosis
•Listen to entire access for changes in bruit that indicate
stenosis
8. Identify Ideal Segment of AVF
• Look and feel for a straight segment of AVF
• Segment must be as long as the needle
length (i.e., 2.5-3cm minimum)Stay at least
5cm from the AVF anastomosis(Fistula)
• The arterial and venous needles need to be 3
cm or 3 finger apart
• Avoid curves, flat spots, and aneurysms to
prevent complications
9. Factors to be considered:
1. Length of session
2. Blood flow rate
3. Choice of dialyzer
4. Anticoagulation
5. Dialysate composition
6. Fluid removal
7. Skill of Technologist and presence
of medical staff.
10. Length of dialysis:
⦿ A first dialysis should only reduce blood urea by 30 %
⦿ For most patient an optimum first session is about 2-3hrs
Blood flow:
⦿ Usually about 150 – 200ml/mint for the first dialysis session.
Dialyzer:
⦿High efficiency dialyzer are not needed for the first few dialysis
session. If they are used, the length of session or blood flow
should be reduced.
Ultrafiltration:
⦿No more than 2 liter should be removed during a first dialysis
session.
⦿ For patient with severe fluid overload – isolated uf
11. 1. Weight
2. pulse rate
3. B.P laying and standing
4. Temperature
5. fluid status
6. blood investigation
7. vascular access patency
8. freedom from infection.
Patient monitoring predialysis
12. Percutaneous venous cannula ( femoral,
subclavian and jugular catheters)
1. Residual heparin or clot is first aspirated from
both catheter lumen.
2. Check the patency of each lumen by irrigating
with a saline filled syringe.
3. saline is administered in the venous limb and
flushed
4. Initiate dialysis after 3 minutes.
13. Apparatus required for cannulation
1. Surgical glove
2. AVF needles
3. Cannulating set(sterile towel, bowl, gauze)
4. Two 10cc syringe
5. One 20cc syringe loaded with heparin
6. Betadine/Iodine solution
7. Saline for flushing
8. Micropore tape
14. Cannulation procedure
1. Wear surgical glove
2. Clean/paint the cannulating arm of patient with betadine solution and
gauze
3. Wipe in circular motion or upwards to downwards
4. First cannulate artery line i.e. towards fistula
5. Second cannulate venous line i.e. opposite to artery line or fistula
6. Cannulate at 45° angle using AVF needle
7. Paste micropore tape so that the needle won’t dislocate after
cannulating
8. Then check the flow of cannulated site using syringe and then flush
with saline
9. If flow of both needle is good, then initiate with the dialysis
procedure.
15. • Set the blood flow rate at 100 ml/min, until the blood fills
the blood circuit.
• Give bolus 10ml heparin
• The priming fluid in the lines and dialyzer is disposed of to
drain until the blood reaches the venous air trap.
• Increase the blood flow rate to the desired level when the
circuit is filled with blood and connected back to patient
• Switch on UF
• Adjust the TMP by opening the clamp of TP.
Initiating dialysis
16. Patient monitoring during dialysis
• Pulse rate, BP every 30 to 60 minutes
• Food and fluid intake
• complication during dialysis
Termination of dialysis
• The blood is forced by pumping a small amount of
saline into the arterial line, then the line is opened to
allow air into the circuit to push the saline and blood.
• Again the fluid entering the patient should be very pale
pink in color.
