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Insertion and Removal of Hemodialysis Access Needles (6.2)

Insertion and Removal of Hemodialysis Access Needles (6.2) - Policies, Clinical, UWHC Clinical, Department Specific, Hemodialysis

6.2

University of Wisconsin Hospital and Clinics
Inpatient Hemodialysis
Department 55400

TITLE: Insertion and Removal of
Hemodialysis Access Needles

POLICY #:6.2
REVISED: October 1, 2014
Page 1 of 6
Nurse Manager: Joan Watson, MS, RN
Director: Ann Malec, MS, RN
Medical Director: Alex Yevzlin, MD


I. PURPOSE

Dialysis Nurses and Technicians will be able to aseptically and effectively insert large bore
needles into a patient’s access for the purpose of hemodialysis. They will be able to safely and
aseptically remove the needles post hemodialysis treatment. The nurse will assess the access for
signs of complications.

III. GENERAL INFORMATION

A. Types of Access
1. Arterio-venous (A/V) Fistula- a surgical connection between and artery and a vein.
a. Forearm - Radial
b. Upper arm – Cephalic, Brachial, Transposed Brachial-basilic
c. Buttonhole (Constant Site) Fistula – has a scar tissue tunnel track that
develops by cannulating the fistula in the exact same spot, at the same angle
and depth of penetration every time.
2. Graft – a synthetic material used to connect an artery and a vein.
a. PTFE (polytetrafluoroethylene) – straight and loop grafts
b. HERO graft – Subcutaneous device that provides continuous blood flow from
an artery into the central venous system. It is classified as a PTFE graft, has a
specific cannulization area, typically in the upper arm and is cannulated
utilizing standard technique. Care must be taken to avoid the connector/graft
ring area, i.e., at least 3 inches from the connector incision.
B. Access Assessment – A thorough physical assessment of the access will be done by the
RN prior to cannulation. Assessment will include:
1. Identifying the type of access and direction of blood flow.
2. Inspect the entire access for signs of swelling, redness, pain, open sores, or drainage.
Palpate the access and avoid abnormal bulges with thin “shiny” skin, hematomas,
flattened, or curved areas. You should hear a whooshing sound (Bruit) and feel a
buzzing sensation known as the “Thrill” along the entire length of the access. A
strong bounding pulse instead of a thrill; may be an indication of stenosis. Cold, pale,
or cyanotic finger tips may indicate “Steal syndrome” (lack of adequate ancillary
circulation).
3. Notify the Nephrologist of any signs of infection, aneurysms, “Steal syndrome”,
stenosis, prolonged bleeding post dialysis or clotted access.


Page 2 of 6
C. Cannulation Considerations
1. Antiseptic technique will be followed when initiating and removing needles. Hand
hygiene should be done and clean gloves should be worn by the dialysis staff prior to
cannulation. Cleanse the skin of the insertion sites with an approved antiseptic.
2. Needle size (17-15 ga), length ( ½ to 1 ¼ inch), and type ( standard vs buttonhole)
should be appropriate to the individual access.
3. Needles shall be placed so that the tip of the needle is 1 inch from the anastomosis
and 1 inch apart; to prevent damage to the surgical anastomosis or recirculation.
4. Arterial needles may be placed antegrade (pointing towards the venous needle) or
retrograde (pointing towards the arterial anastomosis). Venous needles should always
be placed with the flow of blood pointing towards the heart.
5. Tourniquets should never be used when cannulating grafts; but are recommended for
cannulation of fistulas to engorge and stabilize the vessel.
6. Local Anesthesia (intradermal lidocaine injection, spray, or Emla ® cream may be
used at the patient request and ordered by the physician. Emla® cream should be
applied 30-60 minutes prior to anticipated cannulation.
7. Needles will be securely taped using a chevron tape under the butterfly wings; then
anchored in place with additional tape across the top. Dialysis needles and tubing
connections will be secured in a manner to prevent line separation.

II. POLICY

A. The A/V fistula or graft will be assessed by the nurse prior to initiating hemodialysis.
B. Needles will be inserted by the registered nurse or patient care technician after
demonstrated competency or by the patient or patient’s partner trained in this aspect of
care.
C. Needles will be inserted and removed in an antiseptic manner and staff will wear personal
protective equipment, i.e., non-permeable gown, gloves, eye, nose and mouth protection
during the procedure.
D. Newly created A/V fistulas or grafts may only be used for dialysis when indicated by the
surgeon or nephrologist.
E. Hemodialysis needles removed upon completion of the hemodialysis treatment will be
placed in an approved bio-hazard sharps receptacle.
F. Notify nephrologist of excessive bleeding from needle puncture sites and obtain order for
topical hemostatic agents, i.e. Gelfoam®, Thrombin. Excessive bleeding is defined as
hemostasis not occurring within 30 minutes of needle removal.

IV. EQUIPMENT
A. Personal protective equipment
B. Two fistula needles of appropriate type, size, and length
C. Tape
D. Antiseptic swabs
E. Tourniquet, if necessary
F. Saline-filled syringes
G. Tuberculin syringe with 25 gauge needle filled with 1% lidocaine or other local
anesthesia as indicated

Page 3 of 6
H. Sterile gauze pads, Super stoppers, Adhesive bandage (Bandaid ®)
I. Absorbable gelatin sponge (Gelform®) and Topical Thrombin as needed
J. Bio-hazard sharps container

V. PROCEDURE LIST
A. Standard Cannulization of Fistula and Grafts
B. Buttonhole Cannulization of Mature Fistula Sites
C. Special Considerations When Establishing a Buttonhole Fistula
D. Removal of Hemodialysis Needles
E. Excessive bleeding

V. PROCEDURES
Standard Cannulization of Fistula and Grafts
1. Perform hand hygiene, don personal protective equipment, and explain procedure to the
patient.
2. Gather supplies and place on a clean barrier on the chair/bed side table.
3. Perform Access Assessment and select insertion sites.
4. Cleanse the skin of the insertion sites with an approved antiseptic.
a. 2% chlorhexidine gluconate/70% isopropyl alcohol – has a rapid (30 seconds) and
persistent (up to 48 hours) antimicrobial activity. Apply the solution in a back and
forth scrubbing motion for 30 seconds. Allow to air dry.
b. 70% isopropyl alcohol – has a short bacteriostatic action time and should be
applied in a rubbing motion for 1 minute immediately prior to needle cannulation
while still wet.
c. Povidone iodine – needs to be applied for 2-3 minutes and allowed to air dry for
its full bacteriostatic action to take effect.
5. Allow site to dry. Remove gloves. Staff must wear both mask and eye ware/barrier
shield. Put on clean gloves.
6. If local intradermal anesthetic is used, infiltrate the skin over the desired cannulation site
slowly to form a wheal. Aspirate prior to injecting the lidocaine to ensure the vessel has
not been entered. Repeat at both sites.
7. Apply a tourniquet or engorge the vessel with your free hand above the insertion site
when cannulating a fistula. Do not use a tourniquet on a graft.
8. Cannulation using dry needles is preferred, however patients with fragile vessel walls
and/or poor blood return may do better with a wet needle i.e., filled with normal saline.
a. Ideally cannulate the arterial site first, then the venous site.
b. Insert the needle until blood returns, a 45 degree angle is recommended for grafts,
25-30 degree angle for fistula. The degree angle may need to be adjusted to match
the depth of the access.
c. A flash back of blood indicated that needle is in the access. After flash back
flatten the angle while slowly advancing the full length of the needle. Stop if
resistance is felt or the blood bounce stops, then re-adjust position as needed.
d. When using a dry stick partially unscrew the cap to allow the blood to prime the
cannula, tighten cap and re-clamp cannula. When using a wet stick the flash back

Page 4 of 6
may not be seen. Check needle positioning by gently aspirating with normal
saline syringe. Blood return should be easy with no resistance.
e. Tape needle securely using a chevron technique.
9. Repeat steps 6 thru 8 for the venous needle.
10. If blood work is necessary it should be collected from the arterial site using a vacutainer
with luer adapter or syringe.
a. Check cannula clamp, unscrew cannula cap and attach vacutainer assembly or
syringe.
b. Unclamp cannula and obtain specimen.
c. When finished reclamp cannula and remove vacutainer or syringe.
11. Attach a 10mL 0.9% Normal saline syringe to cannula. Unclamp and flush needle to
insure patency and assess resistance. Repeat on Venous needle.
12. When both needles have been successfully inserted follow the procedure for initiation of
dialysis.
Buttonhole Cannulization of Mature Fistula Sites
1. Perform hand hygiene, don personal protective equipment, and explain procedure to the
patient.
2. Gather supplies and place on a clean barrier on the chair/bed side table.
3. Perform Access Assessment and remove any scab over the cannulation site with a sterile
tweezers or 18 gauge needle.
4. Cleanse the skin of the insertion sites with an approved antiseptic.
5. Allow site to dry. Remove gloves. Staff must wear both mask and eye ware/barrier
shield. Put on clean gloves.
6. Using an anti-stick dull bevel needle, grasp the needle wings and remove the tip
protector. Align the needle cannula over the cannulation site and pull the skin taut.
7. Carefully insert the needle into the established cannulation site. Advance the needle
along the scar tissue track. If mild to moderate resistance is met while attempting to
insert the needle, rotate the needle as it is advanced using gentle pressure.
8. Lower the angle of insertion when blood flashes back into the needle. Continue to
advance the needle into the AV fistula until it is appropriately positioned within the
vessel.
9. Securely tape the needle using a chevron technique.
10. If blood work is necessary it should be collected from the arterial site using a vacutainer
and adapter.
a. Unscrew cannula cap and attach vacutainer.
b. Unclamp cannula and obtain specimen.
c. When finished reclamp cannula and remove vacutainer.
11. Attach a 10mL 0.9% Normal saline syringe to cannula. Unclamp and flush needle to
insure patency and assess resistance. Repeat on Venous needle.
12. Follow procedure for initiation of dialysis. (Link)





Page 5 of 6
Special Considerations When Establishing a Buttonhole Fistula

1. Always use a tourniquet placed in the axilla area of the upper arm.
2. Select the cannulation sites carefully. Consider straight areas, needle orientation, and
ability of the patient to self-cannulate. Sites should be selected on an area without
aneurysms and with a minimum of two inches between the tips of the needles.
3. On a mature fistula you can use an existing site to develop:
a. Use a blunt AV fistula needle, grasp the needle wings and remove the tip
protector. Align the needle cannula with the bevel facing up over the cannulation
site and pull the skin taut.
b. It is important to cannulate the developing site in the exact same place using the
same insertion angle and depth each time (same cannulation for 6-10 times by
same person).
c. May need to rotate the needle slightly while advancing down the track
4. On a new fistula
a. Start with sharp 17-gauge needles advance sharp needle gauges as you normally
would, but using the same sites
b. When you reach the ordered needle gauge, continue cannulations with sharp
needles until you have determined the sites are ready for blunt needles.
Removal Hemodialysis Needles
1. Perform hand hygiene, don personal protective equipment, and explain procedure to the
patient.
2. Return blood following the procedure for discontinuation of dialysis.
3. Clamp both needles at cannula and both blood lines and disconnect. Using recirculator
close the circuit prior to disposal.
4. Gather supplies and place on a clean barrier on the chair/bed side table.
5. Open sterile gauze pad dressings and super stoppers as needed.
6. Don new pair of gloves. Staff must wear both mask and eye ware/barrier shield. Patient
should wear gloves if assisting with holding pressure on needle exit site.
7. Remove tape used to secure needle.
8. While holding needle with one hand, cover puncture site with sterile dressing and super
stopper if used.
9. Slowly withdraw needle at 20 degree angle until the entire needle has been removed. To
prevent damage to the vessel wall digital pressure should not be applied during needle
removal.
10. Apply firm constant pressure for 10-15 minutes. To ensure both the skin and vessel exit
site is being compressed it is recommended to use both the index and middle finger over
the gauze pad and the thumb wrapped around the limb forming a “C” clamp. Thrill
should continue to be felt.
11. Apply needle guard cover and discard needle in the appropriate sharps container.
12. Repeat steps 7 through 12 for the other needle.
13. When bleeding has stopped apply a fresh sterile gauze pad and/or adhesive dressing to
the exit site. These should remain in place for 12 to 24 hours.

Page 6 of 6
Excessive Bleeding for Needle sites
1. Perform hand hygiene, don personal protective equipment, and explain procedure to the
patient.
2. Gather supplies and place on a clean barrier on the chair/bed side table.
3. Open sterile gauze pad dressings and absorbable gelatin sponge (Gelfoam) package.
4. Apply absorbable gelatin sponge to needle site and cover with small gauze pad. Hold in
place with moderate pressure for up to 30 minutes.
5. If above is not effective, notify nephrology physician and obtain an order for topical
thrombin.
a. Dilute thrombin per package directions.
b. Saturate absorbable gelatin sponge and squeeze to remove air bubbles.
c. Apply soaked sponge to site, cover with small gauze pad, tape securely and hold
in place with moderate pressure for up to 30 minutes.
6. If above topical thrombin not successful, notify physician again.

V. RESOURCES
A. KDOQI Guidelines for Hemodialysis Access
B. National Kidney Foundation - Fistula First Initiative

REVIEWED:
Jmw08/10/13