1) The document provides guidelines for caring for and maintaining an arteriovenous (AV) vascular access, including an AV fistula or graft. It discusses assessing the access before cannulation, identifying appropriate cannulation sites, performing cannulation safely, and removing needles properly. 2) It also outlines a staged protocol for cannulating a new AV access, starting with single cannulation by experienced nurses and progressing to double cannulation and larger needle sizes over time. 3) Maintaining the access involves daily exercise, avoiding heavy lifting or tight clothing on the arm with the access, and properly cleaning and caring for it before and after each treatment.

1. The AV Vascular Access
REYNEL DAN GALICINAO
SA 1565

2. Taking Care of the
AVF

3. Keep Your AV Access Healthy
1. Feel the thrill every day
2. Do not carry heavy objects with the fistula arm
3. Do not wear watch or other accessories, on this arm
4. Do not use too tight clothes
5. Do not allow drawing blood and IV drip in the arm of the fistula

4. Keep Your AV Access Healthy
6. Do not allow evaluation of the arterial tension in the arm of the
fistula
7. Exercise the arm in order to develop fistula
8. Maintain good personal hygiene (bathing)
9. Wash the arm of the fistula before starting EVERY treatment
10.Do not shave the arm of the fistula
11. Do not scratch the skin, or remove crusts from any wound in the
arm of the fistula

5. Recommended
Exercises

6. Arm Fistula
 Press and release with fast moves, a soft ball
 10 minutes, 6 times per day
 Press repeatedly a clothes-hanging clip
 5 minutes, 6 times per day
 Touch the tip of the thumb with every finger of
your hand, opening your hand after every
touch
 5 minutes, 6 times a day.

7. Upper Arm Fistula
 Use a weight, ≤1.5kg and with slow
movements go up and down, with
your arm
 10 minutes, 6 times per day.

8. AV Access Needle
Placement

9. Assessment Before EVERY Cannulation
 Observation:
 Alterations in the access: Compare to the other arm or leg
 (skin color, circulation, integrity)
 Signs and symptoms of steal syndrome
 Size of the cannulation vein, areas of cannulation, signs of infection,
presence of aneurisms

10. Assessment Before EVERY
Cannulation
 Palpation:
 Alterations on temperature of the arm or leg
 Presence of thrill and pulse
 Auscultation:
 Presence of bruit throughout the access

11. Identify Cannulation Sites: AVF
 The arterialized vein, the segment
must be as straight as possible
 Segment should have at minimal the
size of the needle
 Arterial cannulation ≥ 3.5cm from
the arterial anastomosis
 Distance between needles ≥ 2.5cm
(6cm between the tip of the needles)

12. Identify Cannulation Sites: AVF
 Arterial cannulation maybe in any direction, but when
possible antegrade direction is recommended.
 Venous cannulation always towards the blood flow of
the access
 Avoid aneurisms and doubtful trajectories.

13. Identify Cannulation Sites: Straight AVG
 Divide the graft’ in half’;
 Start cannulating at middle
and move out
 Subsequent needle sites 0.5
to 1 cm apart
 When 2.5 cm from
anastomosis return to start

14. Identify Cannulation Sites: Looped AVG
 Divide at mid point
 Don’t cannulate in the loop area, only
the straight segments
 Dedicate one segment to arterial sites
and the other to venous sites
 Move needle sites 0.5-1 cm apart
 When 2.5 cm close to the anastomosis
return to the start of the segment

15. AV Access
Cannulation

16. Cannulation Site Technique
 Preferable use
rope ladder or
buttonhole
technique
 Avoid area
technique

17. Choose the Right Needle Size
Needle Gauge BFR (mL/min)
17 <250
16 <300
15 <450
14 ≥450
AP >-250 mmHg VP <200 mmHg

18. Prepare for
Cannulation
 Ensure appropriate hand hygiene and
PPE
 Wash arm:
 Transient flora is a source of infection
 Ensure that skin is properly dried
 Ensure appropriate supplies are at hand

19. Skin Preparation
 Clean with antibacterial agent:
 −70% alcohol
 −2% chlorhexidine in 70% alcohol
 Do not go over the already cleaned area with the same cleaning wipe
 Allow adequate contact time: 15 seconds
 −Allow area to dry

20. Cannulate the Access
 Stabilize the patient’s hand
 Hold and slightly secure the skin
 Chose the appropriate angle of cannulation:
 20-35° in fistulas
 45° in grafts
 Cannulate, preferably, with the bevel up

21. Cannulate the Access
 Verify if there is blood flow to the needle, as soon as
the vessel is penetrated
 Always aspirate blood first
 Progress the needle in the same angle of
cannulation
 Verify if blood flow is adequate
 If necessary, as a last resource, rotate the needle
 Release the tourniquet if used

22. Safe Taping – Prevent VND
 Place 1st tape strip over the needle insertion site and wings
 Chevron
 Place 2nd tape strip
 Place 3rd tape strip around needle tubing and secure it

23. AV Access Needle
Removal

24. Needle Removal
 Wear PPE
 Do not apply pressure as needle is withdrawn
 Press immediately upon needle removal
 Remove needle using the same angle performed during cannulation

25. Compression
 Two fingers to compress
 Pressure applied at 90 degree angle to
the skin
 Try to avoid clamps as the pressure is
static
 Involve patient
 Vary pressure to maintain equal
pulse/thrill and control bleeding

26. Post Needle Removal Care
 Apply dressing post treatment
 Adequate to cover site and protect
 Avoid excessive pressure that may restrict
blood flow

27. Cannulation
Protocol for New
AV Access

28. Maturation of New AVF: Rule of 6
 6 weeks old
 >600 mL/min flow
 >6 mm in diameter
 <6mm below skin surface

29. Maturation of New AVG
 2-4 weeks from creation

30. First Cannulation
STAGE I SINGLE CANNULATION
 1st Arterial cannulation (preferable upwards, downwards if necessary):
 Cannulated only by the most experience or accurate nurse in
cannulation.
 Use of 17G needles recommended.
2nd – 3rd Arterial cannulation:
 Cannulated only by the most experience/accurate nurse in cannulation;
use17G needle

31. Double Cannulation
STAGE II DOUBLE CANNULATION
 1st Double cannulation (preferable upwards; venous always
upwards:
 Cannulated only by the most experience or accurate nurse in
cannulation; G17
 2nd – 3rd Double cannulation
 CVC can be possibly removed after 2 weeks of double cannulation
without complications

32. Double Cannulation With
CVC Removed
 STAGE III DOUBLE CANNULATION WITH CVC REMOVED
 Double cannulation
 Cannulated recommended by the most experience or accurate
nurse in cannulation.
 Use of 16G needles recommended until the 8th week or upon
assessment of experience nurse.

33. Double Cannulation With CVC Removed
STAGE IV DOUBLE CANNULATION WITH CVC REMOVED
 Double cannulation
 Cannulation endorsed by the most experience or accurate nurse in
cannulation to the Charge Nurses/ Senior Nurses/Junior Nurses.
 Increase to 15G or 14G upon assessment of experience nurse.

34. VND Risk
Assessment

37. Thank you and Advance