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Fistula Care

Good dialysis needs good access so it is important to keep your fistula clean & healthy at all times, this well help protect  your fistula from infection & help your fistula last a long time.  If you have any questions or concerns about your fistula please contact the homecare team by telephone or Skype.   

A fistula is the surgical joining of an artery to a vein.  The join is internal so you will not see it.  As a result of this joining, blood is re-routed from an artery into a vein, so that the vein and vein walls become larger allowing an increased blood flow.

For dialysis to be efficient and adequate the blood flow has to be in the region of at least 200ml/min (nearly 2 pints every 5 minutes).  A fistula allows a good blood supply to the dialysis machine and is large enough to sustain having needles placed in the arm numerous times a week.

  • A fistula is ready or ‘mature’ when the vein has grown large enough and strong enough to support dialysis needles
  • This usually takes a minimum of 6-8 weeks. 
What is a fistula

Check your fistula on a daily basis so you notice any changes as soon as they occur.

Look for:

  • Redneess
  • Swelling
  • Heat (does the fistula feel warm/hot to touch
  • Pain
  • Weeping (do the sites look wet & discoloured)

 

If you have any concerns about your fistula, please contact the unit immediately on 01332 789919 or 01332 789362

Signs of Infection
Signs of Infection
Healthy Fistula
Healthy Fistula

THROMBOSIS (a blood clot) is the most common cause of fistula failure

INFECTION is the second most common cause of fistula loss 

ARTERIAL STEAL SYNDROME The signs and symptoms of Steal Syndrome are coldness of the fistula hand/fingers, pain or tingling, or poor function of the hands/fingers.  This is caused by the fistula diverting too much arterial blood into the vein.  The hand then does not receive enough blood supply.  If this happens, the fistula can be refashioned surgically

ANEURYSM (Weakening of the vessel wall) can occur from repeated cannulation of the same fistula site.  Large aneuryms limit the available needle sites.  The risk can be minimised by carefully rotating the needle sites to allow areas too heal properly between dialysis

If you have any questions or concerns regarding your fistula don’t be afraid to ask questions, contact the unit or speak to your community nurse, we prefer you to ask rather than worry about it.

Feel your fistula daily to ensure it is functioning properly.  You will feel a vibration which is known as the ‘thrill’ & can listen to the blood flow using a stethoscope, known as the ‘bruit’.  These are signs of a healthy working fistula.

 If you are unable to feel any vibration or hear any flow than please contact the unit as soon as possible - Home Team 01332 789919, Main Nurses Station 01332 789362

Steth Heart

A fistulogram is an x-ray examination to see if there are any blockages or narrowing in your fistula.

 A fistulogram involves the placement of one or more plastic tube(s) (catheters) into your fistula or the artery feeding into your fistula.  The skin over the fistula will be numbed with local anaesthetic before the catheter is inserted.  X-ray contrast material (x-ray dye) will be injected through the catheter and x-ray pictures taken.  You may be asked to hold your breath for several seconds as these pictures are taken.  During the injection of x-ray contrast material, you may experience a warm feeling or a strange taste in your mouth.  Both of these sensations are temporary and will go away quickly.

 After a fistulogram you will monitored for a period of 30 minutes.  Your blood pressure, heart rate and puncture site will be checked frequently during this time.  You may eat and drink.  We will show you how to apply pressure to the fistula if any bleeding should occur at home.

Why do I need a Fistulogram?

 Your fistula or graft allows you to have effective dialysis.  However, problems can arise that indicate there is a problem with the anatomy of the fistula.  You or the nurses may find it difficult to place the needles, the flow through the fistula may be reduced (either the pump speed or the measurements taken on the unit may indicate this) or your dialysis quality may be below the recommended standard.  Other problems may be related to clots, excessive bleeding or swelling of the limb on the side of the fistula.

 Since these problems may indicate an anatomical problem, carrying out a fistulogram allows us to demonstrate that, and potentially correct the problem

This is a non-surgical procedure used to open up blocked or narrowed vessels in your fistula arm.  This is done to improve the function of you fistula.

If the fistulogram shows an area of narrowing or blockage, a fistuloplasty may be performed.  This involves the insertion of a special tube that has tiny deflated balloon at its tip.  The balloon is positioned at the site of the blockage and is then inflated and deflated several times.  If you experience any discomfort during the inflation of the balloon, you will be offered pain relief.

Sometimes if there still is not enough blood flow through the area despite fistuloplasty , a metal mesh tube (stent) may be placed at the site.  The stent will widen the vessel and improve the blood flow.

If the fistulogram shows that a blood clot is blocking one of your vessels, a special drug or mechanical device may be used to dissolve or remove the clot (Thrombectomy/Thrombolysis).

At the end of the procedure, the catheter will be removed.  Sometimes a stitch will be placed at the puncture site to stop the bleeding.  This will be removed by the nurse at your next dialysis session.

The procedure will take up to 2 hours.  Your blood pressure, heart rate and puncture site will be checked frequently, during this time you may eat and drink.  We will show you how to apply pressure to the fistula if any bleeding should occur at home.

  • Exercising the arm can help a new fistula develop faster.

  • Apply a tourniquet to the arm and use a stress ball to squeeze in the hand

  • Do this for 5 minutes, then rest for 5 minutes. Continue this cycle for 30 minutes at least 4 times a day.  

 

(Awaiting picture)

To help take care of your fistula

  • Avoid wearing tight-fitting sleeves

  • Avoid wearing watches or jewellery on your access arm

  • Do not carry heavy goods with your access arm

  • Try not to sleep on your fistula arm

  • Do not let anyone take blood samples from your access arm

  • Do not take blood pressure readings on the access arm

 

Always clean your fistula with chlorhexidine before cannulation.  If using the buttonhole technique, clean the fistula prior to removing the scabs & after removal – always use separate picks provided with the needles for each scab.  One last clean is also needed post dialysis on buttonhole before application of miropiricin .

Fistula Bands
        Procedure for Cannulation of Arterio Venous (AV) Fistulas


Procedure for Buttonhole Cannulation of AV Fistula

 

Procedure for Cannulation of Arterio Venous (AV) Fistulas

This procedure has been designed to adhere to the principles of ANTT, this stands for (Aseptic Non Touch Technique). This technique is used by all health professionals to ensure safe & efficient practice & to reduce the risk of infection. The principles of ANTT that apply to this procedure are:  

 Good Hand-washing

 Hospital hand washing policy

 Hand washing is one of the simplest though most important procedures you can do to reduce the risk & infection.

 http://www.wash-hands.com/the_campaign/wash_hands_quick_video_guide

renal - hand leaning techniques

Protecting key parts

  • The point where the syringe attaches to the needle. 
  • Needle insertion site.
  • The gauze covering the insertion site.

Key parts should be protected as much as possible through the procedure and should avoid being touched, this also reduces the risk of infection. 

Preparing for Cannulation of AV Fistula or Graft

1) Collect together the equipment required:   

  • Renal pack
  • Put on pack 
  • x2 5ml syringes
  • X2 correct sized needles
  • Tape
  • 0.5% chlohexidene (pink liquid)


2) Wash hands with soap and water, according to the hospital’s hand-washing policy.

3) Wipe the table with a Sanicloth wipe and allow to dry. Open out renal pack and open equipment onto your pack (your aseptic field), do not place other equipment in this area.

renal - sanicloth wipes

4) Assess the fistula and decide where to insert the fistula needles. If a tourniquet is required, this can be applied for assessment and then released once assessment is complete. This should be applied away from and above the cannulation sites. 

renal - assess fistula

5) Put on an apron and wash hands with alcohol gel or soap and water. Put on a pair of gloves. 

6) Assemble the fistula needles to the syringes (avoid touching key parts).

7) Prepare the tape for applying to the needles after cannulation.

8) Place the paper towels provided in the pack, under the fistula arm to create an aseptic field around the cannulation procedure. Clean the cannulation sites with 0.5% chlorhexidene solution and allow to dry.

renal - fistula

Cannulation of Fistula

1) Apply the tourniquet if required, attempting to avoid contamination of the needle insertion site.

2) Insert the arterial (bottom needle) at the correct angle & direction. 

renal - fistula needle

3) Once the needle is in place, a flashback (blood) should be seen in the needle, release the tourniquet and aspirate blood into the syringe.

4) Assess the flows on the needle. If adequate, apply the tape with: 

  • A piece of tape over the wings of the needle
  • A piece of tape underneath the needle lumen and then looped round in a horse shoe over the wings of the needle, securing the needle, but not covering the exit site.
renal - fistula needle 1
Once the needle is secured, a piece of sterile gauze should be applied over the exit site and taped in place 
renal - fistula needla 2

Assess the flows form the needle once taped in place & repeat for venous needle (top needle)

Buttonhole Cannulation of AV Fistula

Buttonhole cannulation is a cannulation technique that can be applied to AV fistulas. This technique has been associated with prolonged fistula life.  This technique involves the fistula needle being inserted into the vein into the same hole at the same direction and angle, for each cannulation. This develops a ‘track’ of scar tissues that guides the needle into the vein (a bit like an ear pierced site). Buttonhole technique involves a development phase, where the track of scar tissue is developed, before moving onto the use of blunt needles once the track has developed.

All patients on buttonhole technique will also have 2% mupiricin ointment / cream applied to their buttonhole sites, post treatment after the site has stopped bleeding. This can then be covered by the normal fistula dressing.  This is to reduce risk of infection due to continuous use of the same sites.

Track Development

  • The same 2-3 staff members should cannulate the fistula during the development phase. These staff members should agree on the direction and angle of the needle insertion at the start of the ‘track’ development. This should be continued for 12 – 18 cannulations before blunt needle cannulation is attempted. 
  • Prior to cannulation the scab needs to be removed from the site in the same manner as outlined in the procedure below. The scab picker attached to the blunt needles should always be used for scab removal, even if a blunt needle is not required. Separate scab pickers should always be used for each site

 

Procedure for Buttonhole Cannulation of AV Fistula

1) Collect together the equipment required:

  • Renal pack
  • Put on pack 
  • x2 5ml syringes
  • x2 correct sized blunt needles
  • Tape
  • 0.5% chlohexidene (pink liquid)

 

2) Wash hands with soap and water, according to the hospital’s hand washing policy

3) Wipe the table with a Sanicloth wipe and allow to dry. Open out renal pack and open equipment onto your pack ( your aseptic field), do not place other equipment in this area.

4) Assess the patient’s fistula, ensuring the buttonhole sites are viable to use. If a tourniquet is required, this can be applied for assessment and then released once assessment is complete. This should be applied away from and above the cannulation sites. 

5) Put on an apron and wash hands with alcohol gel or soap and water. Put on a pair of non-sterile gloves.

6) Assemble the fistula needles to the syringes (avoid touching key parts).

7) Prepare the tape for applying to the needles after cannulation.

8) Place the paper towels under the fistula arm to create an aseptic field around the cannulation procedure.

9) Clean the cannulation sites with 0.5% chlorhexidene solution and allow to dry.

10) Soak 2 gauze pieces in 0.5% chlorhexidene solution and place over each   buttonhole site for 1 minute. This helps to soak the scab in preparation for removal.

11) Using the scab picker, remove the scab from each site. A clean pick / needle should be used for each site. Ensure the scab is fully removed, as this can colonise bacteria.

renal - fistula cleaning

12) Clean the cannulation sites again with 0.5% chlorhexidene solution and allow to dry.

13) Apply the tourniquet if required and insert the arterial needle fistula needle at the required angle and direction. The needle should be gently guided into the vein to allow it to follow the developed ‘ track’.

renal - fistula 2

14) Once the needle is in place, a flashback should be seen in the needle release the tourniquet if used and aspirate blood into the syringe

renal - fistula 4

15)  Assess the flows on the needle. If adequate, apply the tape with:

  • A piece of tape over the wings of the needle.
  • A piece of tape underneath the needle lumen and then looped round in a horse shoe over the wings of the needle, securing the needle, but not covering the exit site.

 

renal - fistula tied
Once the needle is secured, a piece of sterile gauze should be applied over the exit site and taped in place.
renal - sterile gaza
Assess the flows from the needle once taped in place & repeat for venous needle (top needle).