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Transcript

- Welcome to the Sono Site webinar,

an ultrasound guided cannulation in the hemodialysis unit.

The next chapter, my name's Chris Pennell

and I'll be moderating today's webinar.

Before we begin, please be advised

that all attendees are muted.

You can type your questions at any time into the q

and a box in the toolbar located at the bottom

or the side of your screen,

and we'll be getting to those questions at the

end of the presentation.

But you can ask those questions anytime

during the presentation if you'd like.

And this webinar will be recorded

and archived for future reference.

So here with us today is Adrian Barrett.

Since graduating with a Bachelor

of Science in Nursing in 1995,

Adrian has been focused on caring for dialysis patients

for the last 27 years.

Her scope of influence on successful hemodialysis practices

has expanded over the years

through her evolving roles in education

and provincial policy initiatives.

Adrian is currently the body access slash independent

dialysis nurse

for the Health Sciences North Nephrology program in Sudbury,

Ontario where she contributes

to a multidisciplinary patient-centered care team

and part of her responsibilities include knowledge sharing

at symposia conferences and workshops

and contributing to task groups

for the Ontario Renal Network.

Adrian is also CNF certified,

which is a Canadian nurse certification in nephrology.

Adrian, we're super excited to have you here,

so I'll go ahead and turn it on over to you.

- Thank you Chris. Welcome everybody.

Thank you for taking the time for attending this webinar.

I'm going to assume you're attending it

because you're interested in consolidating your skills

related to ultrasound guided cannulation in the

hemodialysis unit.

So without much further ado, let us begin.

As Chris mentioned, if you have any questions,

please go ahead and write them in the chat chat section

and we'll address them at the end of the webinar.

Alright, as it stands, existing challenges

to ultrasound use in the hemodialysis unit, let's review

what some of those challenges might be.

Ultrasound guided cannulation is a fairly new practice in

dialysis units

and as a result there's not a lot

of robust information out there that individuals can access

to help guide them.

Along this process of learning this new skillset,

creating this webinars as an opportunity to create one more

of those resources that'll hopefully help you help you.

What I've done here is I've taken some barriers

that have been identified by myself

and other individuals in my role that I network with

and I thought it would be prudent to address

what those potential challenges could be.

'cause they might relate to you as you're watching.

So first of all, a lot of times people say, I don't know how

to use the ultrasound.

That makes sense. This is fairly new device

and it's not something that you might have been trained

to use if your training has occurred a while ago

or if your program is just accepting these devices as part

of their system or something they're thinking about doing.

I don't know what I'm looking at.

And that means on the screen you've got your probe,

you've got your image on an ultrasound screen

and you're not quite sure what to

identify what you're looking at.

Using the ultrasound takes time.

I don't have any time to spare.

Well, you know what I can understand

workloads in healthcare are continuing to increase

and that means that our time is ever more precious.

But let me just say when it comes to using the ultrasound

that while it might take time to consolidate this skill,

it certainly does save you a lot of time in the future

and with any cannulation

because our number one objective when we're cannulating our

patients is not to miss.

And it would be nice to have a skillset

that would help us not miss ultrasound can do that.

It's awkward to use and it stresses me out.

That's perhaps the most predominant one I hear.

And you know what?

It is awkward to use if you're not used to it

and it can stress you out

because you don't know how to use it

or you don't understand what you're looking at

or you're having a problem moving around.

We'll address some of this throughout the webinar.

Why can't I see the cannula in situ when

I check for placement?

Hard time locating that cannula.

We'll talk about ways to possibly rectify that situation

and how do I stabilize the vein when

I'm using the ultrasound?

Good point. We'll address that too.

I cannulate well without it

and the patient doesn't want me to use it.

Well, okay, we will address those issues too as well.

Essentially the learning objectives

of today's webinar are why is the use

of ultrasound guided cannulation considered beneficial?

Two, rolling out an educational plan in your facility

related to ultrasound guided cannulation

and acknowledging the barriers that may need to be overcome.

We'll do a brief overview of how to use the ultrasound

for guided cannulation, specifically walking it in

and we're gonna review some images, identifying issues

with an AV fistula or graft using an ultrasound.

We'll do some case studies, things that might help you be,

that might help you identify

what you're seeing on the ultrasound screen.

Okay, so let's start

with why is the ultrasound guided cannulation a benefit?

Well, it has the potential to decrease interstitial events

during cannulation

and this can potentially reduce the stress

for both the hemodialysis patient as well as the nurse.

And frankly, if at any point

during my working day I can have a reduction

of the stress I might be feeling, I'm going to be willing

to adopt whatever it takes to get there.

It can provide more accurate cannulation than non guided

cannulation, although admittedly it might

take a little bit more time.

It can ident help identify when a vessel is ready

for cannulation acceptable depth

and diameter of that vessel.

So we all know when we're waiting for a fistula to mature,

we're waiting for it to reach the rule of sixes

and one of those is the,

the vessel itself should be no more than six millimeters

below the surface of the skin

and the diameter of the vessel should be about

six millimeters as well.

Well, we can't possibly know the depth

or vessel diameter without the use

of something like an ultrasound that can help us

to identify when a vessel's ready

and mature for cannulation,

it can assist the bedside nurse in identifying the presence

of valves, thrombus, aneurysms, areas of injury,

pseudo aneurysms and vessel branches.

All of these things we're gonna take a look at.

I always make sure that when I make statements like this,

a lot of it is backed up with existing research.

And so you will notice on the bottom of this slide

that the articles that I refer

to do support the statements made as to why cannulation

with ultrasound is a benefit.

If you're going to be using ultrasound in your unit,

what should an educational rollout of it look like?

Well always keep in mind

that ultrasound in the dialysis unit is not being used

as a diagnostic tool.

It's being used as a tool to assist with cannulation.

So do not expect that you should have

to develop the skillset that a sonographer

or ultrasound tech has.

You are a bedside nurse

and you're using this to assist you in cannulating in a

patient's dialysis access.

Help determine which healthcare professionals we expected

to use this tool and who's responsible for using it.

Guidelines on how to do this do not yet exist.

Existing guidelines make recommendations for the use

of ultrasound guided cannulation,

but as I had mentioned in a previous webinar, there needs

to be more research on this particular topic in order for it

to be adopted as a guideline.

We're well on our way to getting there,

but in the meantime, using the existing research

that we have and moving forward

and potentially doing new research is something

that will only assist in this endeavor.

If you're starting from scratch, more

and more information is becoming available.

As it relates to ultrasound guided cannulation,

there are two articles that I reference here.

One of them comes from Rosa Marina Etal

and it is a development of competencies to use to the use

of bedside ultrasound assessment and cannulation.

It gives you a really good idea of potentially

what you can do to structure your educational rollout if

you're having problems trying to determine where to begin.

And then the other resource is one of my favorites

and it's BC renal.

They have their guidelines, the recommendations

and standards online

and they have some excellent references as it comes

to ultrasound use in the hemodialysis unit

that you might be interested in looking at.

So starting out ultrasound might be new to you,

so make sure you complete your programs Education related

to ultrasound guided cannulation in the hemodialysis unit.

I think at this point you need to be aware

that Cyte has an existing educational guide as well

as recorded webcast to assist in this endeavor.

You can access this.

It was a webcast called Behind the scan to see us

to know it was from November, 2020

and that's the first of this series.

This particular webcast is a continuation of

that one expanding upon information that was given.

There it is, gives you more of a robust overview

of the guidelines and existing research review

of why using it.

Why using that is using ultrasound is a good idea

and it goes over the basics of ultrasound.

You can also access the guided cannulation

and dialysis court that's online on Theano Site Institute

and it's used

to introduce guided cannulation in the hemodialysis unit.

With an online test, it's often recommended

that you actually have your,

your staff nurses complete this particular course

before you start your education.

It helps 'em to give,

give them a good foundation of knowledge.

In addition to today's presentation, the assistance

of your regional sono site clinical application specialist

for education on the device itself can also enhance your

education program.

We we use Kristen

and she's an invaluable resource for both myself

and all my bedside nurses.

Familiarize yourself with the device in your unit how

to turn it off and on

because while I'm talking about cyte ultrasounds,

there's a few different models

and some of the uses buttons, touch screens may

or may not be available on the model that you have.

Familiarize, oh, engage in a simulation learning if

at all possible.

So that means the use of blue phantoms

or artificial limbs

with dialysis access is embedded in them.

Use of your facilities infection control standards when

using this equipment must always be forefront in your mind

and please follow those policies and procedures.

If you're using the ultrasound on a patient

for the first time, make sure you tell them why

you're using this equipment.

Okay, so when it comes to learning to adopt ultrasound,

I'm going to assume you're watching this webinar

because you are interested in learning,

but you might have evidence

of other individuals in your unit

who are not interested in adopting this particular skill set

and there's a lot of pushback on it.

There's a lot of reasons why that might be happening.

Here's, here's a few I'm gonna go over.

Someone might say I cannulate well without it.

The access pressures on the dialysis machine suggest I don't

have issues with cannulation.

So what's the point of using it?

Well, studies suggests that cannula placement is the cent

cannula placement in the center

of the vessel is only achieved 10%

of the time when somebody cannulate.

If you have accesses that are not challenging

or a skillset check, second to none, consider it using it

for assessing maturing accesses.

So if you really feel you don't need it for cannulation,

it can still be a vital tool for you to use.

And it's also a nice tool

to have when a complicated access does

eventually present in front of you.

Having a consolidated skillset on how

to use it in such a circumstance is invaluable.

The patient doesn't want me to use it.

If the patient has encountered unpleasant experiences

with someone else who's used this device,

their comment might very well be founded.

I think it's worthwhile to determine

where their anxieties come from

and address them high anxiety or stress.

And this is either on the side of the patient

or the individual using the ultrasound.

The nurse, if use of this device causes stress practice

with simulation beforehand, it's completely reasonable

to consolidate this skill to a certain degree prior

to even touching a live arm.

I actually have embedded at the bottom

of this particular slide, references to an article on

how you can make your own homemade blue phantom

to simulate using for cannulation.

I have personally done this recipe

and it has been very helpful.

So if your program doesn't have access to a blue phantom,

there is, there are ways to produce one that can help you

with simulation learning.

And there is evidence

that using simulation learning when learning how

to do a skillset like this can lead

to certain competencies even

before you even touch a live person.

So that actually can really help to reduce your stress.

There's no room, there's no room

to put this ultrasound machine.

Well consider the fact

that if the device becomes invaluable tool in your own

personal kit, you're gonna make room for it

because it's value has proven its importance your time.

And again, let's start with some basics here.

Holding the probe. So these are just little

reminders I'm gonna go over right now.

When you hold the probe, one of the issues you can have

is your objective is to get the vessel in the middle

of the screen to get that big black circle in the middle

of the screen and for it to stay still holding the probe.

Sometimes you can experience a little bit of

what I call drifting from side to side.

That can happen because the probe while you're using,

using slippery ultrasound gel

and it can move easily over the arm.

If you take a certain part of your hand

and you actually secure it against the patient arm,

that can help to minimize that drifting that you experience.

So the picture on the left depicts one of the ways

that you can stabilize the ultrasound probe so that it does,

the image itself doesn't shift on you

when you're viewing the vessel with the ultrasound,

there's two ways to view it.

One is called the long axis view

and the other one is the short access view

or longitudal longitudinal versus cross-sectional.

What that essentially means is at the base of the probe,

the ultrasound waves come out

but they only come out at about the thickness

of a credit card.

So you can look at a vessel two waves, you can look at it

on the long axis or you can turn the probe the other way

and look at it on the short axis or the cross one.

So for example, here's an example of a longitudinal view.

The vessel itself is gonna look like a river flowing from

one side of the screen to the other.

This is a cross-sectional view.

So this is like looking at the vessel being sliced.

So knowing the difference between those two views can

help you with orientation.

When you are using the ultrasound probe,

the arrow on the probe follows your guideline or center line

and that's if you use the guideline or center line.

I recommend that you always use the guideline.

The dots on the guideline fall down the center on the screen

and they always match up with the arrow

that is on your probe on a guideline.

Those dots have specific distances between each of them.

So that'll help you determine the depth

and the diameter of the vessel,

which is important when you're trying

to decide am I approaching this from the usual angle,

is it a deeper access where I have to increase

or is it a very shallow access where I have

to decrease my angle of entry?

The distance between that guideline is five millimeters

or half a centimeter and as you change the image depth,

you're gonna change the distance of those

dots going down the center line.

So the guideline is what I recommend,

but the center line is also very helpful.

Alright, so this is a clip of using the ultrasound

for access assessment.

Someone has taken the probe

and is running it up, this individual's dialysis access,

they're determining the depth and the diameter

and it's helping them to determine exactly

where they're going to decide

to put the cannulas when they put in the venous

and arterial sites.

So this is a basic way of using the ultrasound.

If you can use it to assess sys

assess accesses on a go forward, it's going

to help you consolidate the skillset, moving the probe,

visualizing the screen.

It'll help you consolidate that skillset.

Here we have an example of exactly

what a fistula looks like when it's captured on a

cross-sectional view with your ultrasound.

Usually it's gonna present as a nice big circle,

at least five millimeters in diameter.

Recognize that if you're not seeing it as a circle

and it's a fistula that you're looking at,

you might be com putting a lot of pressure on

that probe and compressing it.

So make sure to use a feather touch

whenever you use your ultrasound probe.

Here is the double wall of an AV graft,

PTFE graft polytetrafluoroethylene.

It's interesting but this is a fairly pristine graft

and it shows up quite clearly as a double wall.

So that's how you would tell the difference

between a fistula and a graft.

Your graft shows up as a double walled vessel.

Alright, so you're ready to go.

You're gonna start using the ultrasound

for guided cannulation.

The first thing you're gonna to do at the bedside is you're

gonna acknowledge your physical comfort,

adjust the chair or the bed.

The patient is going to be resting in to a height

that is comfortable for you.

Hunching over and cannulating is one of the many things

that dialysis nurses do that's not good body mechanics,

I don't think we can recognize

how being in an uncomfortable physical

position can increase our physical stress.

So make sure that you're not putting any undue stress on

your back or your joints when you're cannulating

and try to move the equipment around so

that you have the most comfortable ergonomic

setup that you can have.

Make sure your patient is comfortable.

Guess what can happen when an individual is in a relaxed

state, vasodilation vasodilation means that

that vessel, it's gonna get as big as it can possibly be

and it's gonna be a bigger target for us to hit.

So not only does your physical comfort matter,

but your patient's physical comfort matters.

Let them adjust and get comfortable in the chair or bed

and get to everything ready to go, nice

and comfortable and then proceed.

If you have the luxury of accessing a mentor to coach you

through the process, if this whole new skillset is something

that causes stress for you, access that mentor,

have them coach over your shoulder.

You might decide to say them, okay, so I'm going to do this.

Could you let me know when I'm doing something wrong?

Or you might say to them, could you just observe while I do

it and then at the end of it let me know

what I could have done better.

Or you can say something like,

can you coach me the whole time?

Tell me what my next steps are.

Say things out loud with this mentor so that they know

how they can be of assistance to you.

Acknowledge it can take up to 500 cannulation

with ultrasound to become moderately proficient.

That's a lot of cannulation,

but when you think about how many you do in a year's time,

it's not even, it's much more than that.

So if you take the time to use it on a regular basis,

it won't be long before you start be starting

to build up experience with using it with your patients.

Set up the equipment to facilitate comfort to when in use.

So oftentimes it can be, hey, there's no room for this.

Yeah, you know what? I have to agree with you.

Dialysis units, there's a lot

of compressed things happening in one space.

It does mean when you wanna put the ultrasound in the ideal

position that you have to move equipment.

I personally like to be able

to look at the ultrasound screen without putting a lot

of undue stress streaming my neck,

twisting to have to look at it.

So what I like to do is I have the patient in front of me,

I try to put the ultrasound

behind their shoulder like this picture depicts.

Sometimes the patient is actually very interested in what's

going on and they wanna see it too.

I just move the ultrasound over to a little a little bit,

have them move their arm over so that I'm facing it better.

So always pay attention to where the equipment is.

If it's in a place that's easy for you to see,

it's gonna keep you more relaxed.

Relax. When you get to the bedside,

it's important to always relax.

Here's a picture of a nurse

who came home from nice long day at work

and decided to watch tv.

Fell asleep with her puppy.

Okay, yeah, maybe not that relaxed,

but when you get to the bedside, taking a few deep breaths

and trying to think of pleasant things can actually help you

with your stress level.

If you present at the bedside with the undue amount

of stress, what makes you think that the patient can't pick

that up immediately?

They know a stressed nurse when they see one.

There's a lot of things happening in our world

and there could be a lot of things

happening during your workday.

Some days go way better than others.

It's okay to be stressed, I'm just telling you

to acknowledge it and try

to do the little self self-care things

that will help you dissipate.

Deep breaths, relax the shoulder, move forward.

Alright, so now we're gonna start with the process of

how we actually cannulate using ultrasound guidance.

This is going to be a condensed version of what was shared

with you in the first webinar.

We're gonna talk about walking it in using the

cross-sectional method.

The biggest issue I see with individuals who are trying

to adopt this skill is having the capacity

to know at all times exactly where the tip

of the cannula is located.

When you have a cannula underneath the ultrasound probe,

the only way you can know

that you're going looking at the tip is if you go

past the cannula.

So when you cannulate,

the first thing you're gonna do is you're gonna line up your

image and you're going to take your cannula

and watching the arm and the probe,

you're gonna cannulate into the arm.

When you feel that that cannula has gotten

underneath the probe into the sound waves, you're going

to turn your head and look at the ultrasound

and you should see a bright white spot.

Then you're gonna make small movements with both the probe

and the cannula because you want to be assured

that you're looking at the tip of the cannula.

You're going to move your probe past the cannula.

So now the cannula is no longer visible in your in the

screen of your ultrasound machine.

Okay? So then you're gonna move the cannula forward so that

that bright white dot, which is what the cannula looks like,

shows up in the middle of the vessel again

and then you're gonna repeat that process.

The movements you are making will be very small,

very small fractions of an inch, only millimeters

of distance for both the probe and the cannula.

So what I expect to happen when you cannulate,

even though we only have an inch to work with when it comes

to a cannula, you're gonna break

that inch down into eight sections.

You're gonna put it in the vessel

and then you're gonna move very slowly one at a time

and walk it in keeping the tip

of the cannula in the center of the vessel.

Always know where that tip is located.

So you move the cannula forward, you move the probe forward,

you move the cannula forward, you move the probe forward.

Here's a short video clip of

what walking it in from a cross-sectional view looks like.

You'll notice that that cannula shows up

as a bright white spot in the middle of the black vessel.

And what I'm doing is I'm moving the probe forward

until I lose sight of that cannula

and then I'm bring in the cannula back

into the field of view.

Until I have no more cannula to cannulate, I am then assured

that I've got the device in the right area

and it's going to function as well as it possibly can.

Here's another example of walking it in.

You'll notice in this circumstance though,

I have a tremendous amount of gel that I'm using

before I put my probe cover on.

On our program uses probe covers on our ultrasound.

It's part of part of our infection control

and that's what you're seeing here.

So the surface of the skin is actually

lower than what it is.

It's at the first.as opposed to the top of the screen.

But that's another example of

what walking it in using a cross-sectional view might look

like if you're using the ultrasound.

Okay, here's a good question.

What do we do about a vessel that moves around?

Well, you'll notice on the image on the left,

this is usually approximately the hand setup you might have

if you're cannulating without ultrasound,

you've got one hand to stabilize the vessel,

especially if it's a rurally poy one

and the other one's got the cannula.

So you're able to hold things still well, you move forward.

You no longer have the luxury of having that hand

to hold the vessel clear

or hold the vessel in place when you're cannulating.

If you're using an ultrasound machine

that's now holding the probe.

So what should you do?

I recommend with fistulas in particular to use a tournkey.

This is something that's already embedded in vascular

guidelines from K dokey and Canadian

and other global guidelines that exist

and I do recommend using it.

On the right here is an example of a reusable tourniquet

that we would give to our self-care patients.

So it's the same patient using that all the time

and our disposable turnkeys that we would use on fistulas.

What will happen is, is that

using a turnkey will help the vessel to become engorged.

And if it's engorged it has less

of an opportunity to roll around.

But remember, you're also now using a device that it

tells you exactly where the vessel has rolled to

and exactly where your cannula is.

So if you do have a vessel that tends to move around,

having the ultrasound allows you to know where it's gone

and how to correct to get the cannula in there.

Small movements

and directional corrections will help

to compensate for that.

I also tell people

that let's say you have an access in the forearm

and you're using a tourniquet, don't put it too far up the

arm because it's not gonna have the engorgement

effect that you might want it to have.

Bring it closer to the access

but not so close that your vessel appears to be compressed.

'cause the turnkey's too close to your insertion site,

engorging the vessel with a turnkey will help stabilize it.

Alright, so we talked about the basics of

of cannulating with ultrasound.

I'm assuming that you here might have some experience

with it, but what you're looking for is more information.

In particular, what am I looking at

when I use the ultrasound?

There's a variety of things that you should be able

to identify when using the ultrasound for guided cannulation

and a few of those things are determining the difference

between a vein and an artery,

what a thrombus might look like, hematoma

or injury to the tissues, valves within our vessels, areas

of injury to the tissues cannula,

what does it look like when it's in place?

Branching vessels

or collaterals on our existing fistulas using color

doppler and what that could mean.

Something called artifact.

And that's just to name a few things.

So let's review some images about cases

that I've come across

and questions that I've had about what am I looking at here.

So first of all, we're going to determine the difference

between a vein and an artery.

They look very much alike insofar

as they're both round black circles.

So in this particular circumstance

what you're looking at is a fistula

that has actually not surprisingly a little bit of injury

to the anterior or top wall.

Underneath that fistula is another vessel that is smaller.

It's only a few millimeters away

and it's pulsatile that is the patient's artery.

Now it's deep enough that you may not hit it with a cannula,

but if you were approaching this access

and using a very steep angle of entry,

there's a small chance that you inadvertently

cannulate that artery.

And we all know we don't want that

to happen when we're cannulating.

We wouldn't have known that this artery was there

because it wouldn't be palpable.

Below the vein, the ultrasound machine allowed us

to identify its presence

and this is actually gonna help us dictate where we're going

to cannulate in this circumstance.

I would recommend not inserting the cannula in this area

just to be on the safe side.

You don't wanna inadvertently miss and puncture the artery.

This is another video clip of a vessel that travels

underneath a fistula so it's not running in parallel

with it, but it's running underneath

and it happens to be an artery as well.

And you'll notice in this particular clip

that this vessel is very close to the fistula

but only for a small section of the whole fistula itself.

But it's nice to know that it's there.

'cause once again, if I was picking areas to cannulate,

I wouldn't pick the exact section where the artery is just

below the fistula in the circumstance.

Another thing that's good to know between arteries

and veins is that you push down using the probe

a vein, which is our fistulas is made up.

It might collapse, but the artery,

because it has higher pressure in it tends to stay round.

So that's another way

that it can help you identify the

difference between the two.

Now let's talk about thrombus or clots.

One of the things that I think we're all aware of is

whenever we have an interstitial event with patient,

it leads to injury, injury inside the vessel, injury outside

of the vessel and sometimes that damage

to the vessel wall leads to the formation

of a clot or a thrombus.

Now surprisingly with the use of ultrasound, I've been able

to determine that in some circumstances, even

with a clot formation, if you leave that access

and you assess it the next time they present

for dialysis treatment, sometimes

that thrombus has spontaneously resolved.

It is no longer there,

but sometimes it continues to be there.

This is an important piece of information,

especially if your program does declotting of accesses.

Your nephrologist might wanna know, okay,

when did this potential clot form,

how long has it been in place?

Because that can dictate the plan

of care On a go forward basis.

Sometimes after a patient has had an interstitial event,

you might go to cannulate

and you're having issues, you're not getting flows

and it might be because you're cannulating in an area

where a thrombus formation is.

Having the ultrasound allows you

to actually identify something there.

Using the ultrasound to assess and access one treatment

after it's had a in an interstitial event

can be very helpful.

It can allow you to avoid the areas of thrombus

that you might come across.

So here's an example, a clip of a fistula that has a couple

of thrombus in it.

So this is a upper arm access

that the probe is being moved from the

elbow to the shoulder.

And this individual had an interstitial event,

the previous dialysis treatment,

and they had two areas where the thrombus formed.

So essentially a thrombus looks like a gray area in the

black circle

and it can present in any number of shapes,

sizes in the middle on the wall.

Being able to identify when it's there is helpful.

There's a small thrombus here

that you see on the right hand side of the vessel on the

inside it's stuck to the vessel wall.

It's very small but it's moving there.

Here's another thrombus formation.

You can see that these accesses remain patent.

So it's just a question of what to do about it.

If you're able to even identify it's there,

then you can call in your vascular nurse

or your nephrologist, your interventional nephrologist,

your interventional radiologist to have a discussion about

what this means and what should you do

with the access on a go forward.

Alright, so in this circumstance there was some question as

to whether or not this individual had a carotid access.

This nurse took a video clip and asked me to go

and look at the video of the doppler.

So what we see here is a little bit of color outside

of the vessel itself

and that's a little bit of artifact

that happens moving the probe itself is producing the

colors, but it's not indicative of a tremendous amount

of flow in the access inside the vessel, which is round.

There's a lot of gray area.

You'll notice that there is a very small amount

of flow through here.

So this access did have minimal patency,

but it was pretty much clotted.

We ended up sending this individual for angioplasty

and declotting, which was successful.

But if you're interested in learning exactly how

to use the color doppler with your ultrasound,

I do recommend that to access your, your mentor,

your educator or the sono site

clinical application specialist

to help you determine how to use that.

So once again, here's a thrombus

that's adhered to the vessel wall.

There's another one, this is an older thrombus.

This particular access was not functional anymore,

but thrombus had been there long enough

that our team decided that declotting was not an option.

Alright, let's talk about valves in the vessel.

Knowing that all of our fistulas are made up of veins,

it is possible that every now

and again we're gonna find a a valve

and more often than not, especially

with say a venous cannulation,

that's not gonna make much of a difference.

But with an arterial cannulation that goes well

and then all of a sudden you don't get flows.

You might wanna know is there something in the vessel

that's obstructing it

and it could be the presence of a valve.

So knowing what they look like

and being able to identify them can help.

So here's a video clip of a metal cannula in a fistula

and you'll notice that there's a valve

that's happening here.

So this particular access,

there was a small back walling event

and you will notice that there's a bit of edema

underneath that cannula.

And there's a narrowing of the vessel right

where the cannula tip is sitting.

The nurse wanted to know that she hadn't caused

so much damage that she wasn't going to get flows

and was surprised to find

that there were valves located at the end of the cannula.

So that's just a little interesting FYI

Hematoma bruising areas of injury.

So this particular patient I I took a picture

of the bruising that had occurred in her arm.

She had an interstitial event in previous dialysis treatment

and the left side is a video clip of that particular area

of her access that's circled in red.

You're gonna see here that she had the buildup of fluid

around her vessel and it was still present.

The next dialysis treatment, it presented as firm tissue.

When it was palpated it was tender to the touch.

And on the ultrasound image it looks like pockets of fluid,

collections of fluid.

I like to say it looks like what bodies

of water would look like if you were up in a

plane looking down.

So those blackened areas are fluid collections areas

of either blood or serous serous of fluid that has collected

after an interstitial event.

This is an interstitial event that resulted in injury

to the anterior wall or top wall of this fistula.

Getting an injury to the anterior wall can often happen

if your cannula doesn't get all the way in

and you're kind of scraping the vessel wall it,

it might become inflamed.

You might get a little bit of thrombus formation and edema

and this is what it would look like.

Once again, this is an area

of injury in this particular axis is located on the

left hand side of the vessel.

There's a little pocket of fluid that happened due

to an interstitial event.

The tip of this cannula just poked

through the sidewall briefly causing this injury.

Alright, Teflon cannulas, those are the plastic cannulas

that you may or may not have experience using,

but it's fascinating to know

that you can actually see these quite nicely using the

ultrasound on the right here I have an example of one

and these particular types

of cannulas have blunt ends, flat ends.

They also have holes, usually about four of them

that are located around the end of the cannula.

One of the interesting things about this, this is

that in order for the cannula to function maximally

with the best possible flows during your treatment,

you have have to get not only the cannula in

but all four of those holes all the way into the vessel in

order for it to function well.

If you do a longitudinal view of your Teflon cannula

after you've cannulated, you should be able

to see those holes

and determine if you have them all in the vessel.

This is a little bit better image

of such a Teflon catheter in place

and it looks like the cannula has been chewed on.

It hasn't. That's a depiction of the holes.

All four holes have made it into the vessel.

So this particular cannula is optimal in place

and did provide us with excellent flows

during the dialysis treatment

assessing with Doppler.

Okay, once again, I do recommend that you get somebody

to show you how to use the doppler on your

particular device.

Doppler allows you to determine if there's flow

through the access and that's what we use it for.

Sometimes patient might have an interstitial event

and we're unable to palpate a thrill

because of the amount of edema that's located in the access.

Using the color doppler allows us to determine

that there is flow.

As I had said in the previous webinar, don't get confused

with the varying colors.

You're going to see blue, red, orange.

That is simply the difference

between blood flowing towards the probe

and blood flowing away from the probe.

A lot of our accesses are very high flow, have a lot

of turbulence and that's why you're going

to see multiple colors.

So this will allow you

to determine if an access still has flows.

If you're questioning something like I thinking this is

clotted, pulling out your ultrasound

and using the color doppler will help you

to determine if there are,

if there is still patency in that vessel.

Pseudo aneurysm.

So I think we all know

that an aneurysm is when a vessel wall becomes thinned

and enlarged and sometimes it can result in the outcropping

or a bulging of the vessel in only one area.

A pseudo aneurysm is different.

That is when you have completely compromised

the vessel wall.

There's a hole in the vessel wall

and sometimes what happens is the tissue

that surrounds the vessel starts to pouch out.

So you're getting blood flowing into that pouch

and back into the vessel.

In this particular circumstance, this was a vintage graft

and the patient presented with a bump that was new to them.

Not surprisingly,

the previous treatment they had had an interstitial event

on the left hand side you're gonna see that

that bump looks like, looks like it's a hole in the wall.

But in order to confirm whether

or not it was, I used color doppler

and confirmed that yes, blood was flowing into

and out of that outpouching, making it a pseudo aneurysm.

The on-call nephrologist was accessed

and it was determined that a plan of care was made

to address this particular issue.

So this was good to know.

The patient too was made aware

and this patient having the cognitive ability to do so.

I advise nurses to avoid

that cannulation while we made the plan of care and

and had a plan of action.

So color doppler can be very helpful.

Here's another example of an injured vessel wall.

The anterior or top wall,

almost always we're gonna see injury to a a vessel wall

after there's been a failed cannulation.

You'll notice just to the top

and the right of this particular image is a

little pocket of fluids.

So not only did we injure the vessel wall,

but some of the blood from

inside the vessel did leak out into the connective tissues.

So that's what we're looking at here.

This is an even bigger injured vessel wall.

The anterior wall, somebody back walled quite impressively.

So not only did we get a leaking of blood into the tissues

underneath it, but the thrombus formation

and inflammation of the vessel wall occurred.

We still had patency of the access.

We were able to use it on and go forward

because it did resolve in between dialysis treatments.

But we definitely chose not to use this area for cannulation

until it it the injury cleared up.

This is another example of injury to a vessel wall

with top right hand, top left hand side rather.

Here is injured interstitial event.

Again, once again top

wall due to injury.

Now let's talk about the longitudinal view

of this sharp cannula with an example of artifact.

In this particular circumstance that cannula is really easy

to see and it's obviously in a graft right there,

but there appears to be some kind of echo effect

that happens after the probe and that can confuse you.

It happens after the cannula actually,

that can confuse you in determining

exactly where the cannula is.

The presence of that artifact is normal.

You are and occasionally will experience it, especially

with a metal needle from which the sound waves bounce

off very easily.

So they might bounce back and forth causing this artifact.

And like I said, you can see here

that this is the double wall of a graft.

Using the calipers is a very handy thing to have,

especially if you are tracking the maturation

of a newly created fistula.

And you wanna know that the diameter is increasing

to the point where it's gonna be easy to cannulated.

So using the calipers, that's something that your mentor

or your clinical educator

or your SAO site individual can help you

determine how to use.

In this particular circumstance, it was used to measure the

diameter of the vessel

and you'll notice on the bottom left hand side there,

it gives you the exact measurement

of the diameter of the vessel.

This one was almost ready to use.

This particular access was somebody

who was assessed in our pre-dialysis clinic

and we're waiting to see if we could start dialysis

and if their access was ready

using the ultrasound

to determine things like branches of vessels.

Sometimes you'll have accesses that are maturing poorly.

Sometimes that can be related to the presence of collaterals

that are stealing blood from the fistula itself.

Using the ultrasound will be able give you the opportunity

to determine if there are vessel branched vessels.

And also if you're going to be cannulating somebody

with multiple branches, you're going to want

to avoid putting the cannula tip anywhere near where

that branch occurs because there's increased turbulence.

So this is another assessment of a vessel. Very nice.

Somebody took the video. You notice here they got a little

heavy with the probe as we moved up compressing the vessel

itself, but it looks like there's gray stuff in there.

Adrian, is that, is that a clot? No, that's artifact.

That's artifact because this particular nurse was very adept

at moving the probe up quickly

and that quick movement of the probe led to that kind

of confused, messy image there.

So this was a fully patent access,

but we weren't looking at a thrombus here.

We were just looking at some artifact

from moving up so quickly.

The probe not making full contact

with the skin surface during assessment.

You're gonna notice on the left hand side, left hand side,

there's almost lines and blank and shadowing going on

and that's simply the probe not making full

contact with the skin.

Part of it was off the skin

and it also could be due to the fact

that you're not using enough gel when you're

using your ultrasound probe.

So that's something when you see those lines down the side

and you see blank spaces when you should see some gray stuff

in there, then it could be just how your probe is,

is making contact with the skin.

Here's vessel injury from a previous interstitial event.

This this individual presented with substantial bruising.

You notice on the left right hand side of this vessel,

there's a huge pocket of fluid right there.

So my concern when I was looking at this particular access

in this particular interstitial event is it was not clear

to me if that was just a hematoma, a pocket of fluid

or if it was a pseudo aneurysm

because it seemed awfully large.

So I pulled out the color Doppler option on this

and I took a look at that area.

This is the color doppler directly over

that pocket of fluid.

There is no movement of the fluid in that pocket.

So I was rest.

I was assured that the vessel was fully plate patent

and that remained an area of injury

that just needed time to resolve.

Here's another example of vessel wall injury.

This is substantial injury all the way around a small access

that had a large interstitial events

with depressive edema and bruising

and this is how it showed up.

You'll take a look at that vessel.

The vessel walls are not clearly delineated

because they're like what I call angry.

They're emus, they're injured, and this access needed rest

before we could use it again.

Thankfully in this circumstance,

this person had a dual access

and we relied on their central venous catheter until all

of this injury was able to resolve over time.

Recognizing that the time it takes

to resolve this injury is variable between people.

It can be a week to two weeks, all depends on your person.

Another example of a vessel wall

that's not clearly delineated

with obvious damage on the anterior portion

of it yet.

Another example, you're gonna think we're

terrible in my program.

All these interstitial events, no,

that was just me taking advantage of properly assessing.

Not only was there a large interstitial event,

but there was a substantial amount of thrombus formation

inside this particular vessel.

This patient needed to be scheduled

for a declotting of our access.

We did not have success declotting this access when they

presented in the radiology department

where we do our dec clots,

the thrombus was even more extensive

and could not be resolved.

So this individual ended up getting

a central venous catheter.

Here's a longitudinal view of a vintage fistula.

This is what it looks like after multiple cannulation.

There were no areas of injury, bruising

or edema on this axis.

I just thought it would be a good example to show you of

what a vintage fistula looks like.

This particular fin, the fistula was 12 years page.

Here's walking it in using the longitudinal view.

That's something that a lot of people

might originally try to do.

I like the cross-sectional.

Walking in in this particular use

of the longitudinal view might a bit challenging

for some individuals

and there's a lot of reasons why not getting an optimal

longitudinal view is hard.

So in this circumstance there you see the,

you see the cannula

and you're able to continue your cannulation

without back calling.

That was easy because that particular access

was very straight.

This particular one is a damaged access

where we had limited capacity to cannulate.

You'll see that the interstitial event was

on the right hand side.

So we were using ultrasound to ensure

that we had good cannula placement

and this lots of corrections

and direction needed to happen here.

And then when it was done, an attempt

to get a good longitudinal view of this

cannula in situ was had.

But you see it wasn't, it wasn't easy, it wasn't clear

and concise like the previous image was.

And there's a reason for that.

So if we were to look at these particular pictures here,

the green line depicts the placement

of the cannula in the vessel.

Each one of these cannulas are good enough

for a good dialysis treatment.

But if you put the probe over top,

the one on the left here is nice and straight

and it would be easy to see a longitudinal view.

The one in the middle, it's not, it's not easy to catch.

You'll only catch a certain portion of the cannula.

So you might see the whole vessel,

but you'll only see a portion of the cannula.

So you might get frustrated

how come this longitudinal view isn't working?

And in the end, if you have a fistula that has,

is very torturous with not a lot of straight sections,

it might be extremely difficult

to get a meaningful longitudinal view.

And that's why I always recommend

to use a cross-sectional view,

especially if you have an access

that isn't straight up the arm.

And we all know those are becoming very limited.

Here's a cross-sectional view of a stent in situ.

Some programs use stents, others do not.

Some programs say, say you can cannulate through a strength,

others say you should not.

But it's nice to be able to identify it so

that you can follow your existing program policies

and procedures When it comes to a stent.

In general, stents are made up of the same material

as our PTFE graphs are,

but they have an infrastructure, like a scaffolding that's

almost like a wire that holds it all together so

that therein lies the debate, cannulate or not cannulate.

So in conclusion, I hope

that this particular information I've shared

with you today has allowed you

to visualize a few more circumstances

and be able to identify what they are.

I think what you need to take away from this particular

webinar is number one, have patience yourself when it comes

to using ultrasound for guided cannulation.

This takes time.

Acknowledge the time that you do have

and use it effectively.

When it comes to the ultrasound, do your best,

whether you're the bedside nurse

or the educator, rolling out this new skillset

to create an environment that is conducive to learning.

Recognize your stress levels.

Recognize how you're talking to your peers

and to your, to the individuals that you might be teaching.

Recognize when it's time to teach the theory

and when it's time to coach.

You'll notice that previously I was talking about when you

present at the bedside to help somebody,

it's always worthwhile to ask them,

what is it that you want from me?

Do you want me to stand back and not say anything?

Do you want me to correct maneuvers that I see

as being not quite right or do you want me to coach you

and tell you next steps the whole time I'm going through it?

What I usually do when I'm introducing ultrasound

to a new staff member is I have them do all

of the virtual education, tri sub simulation,

and then at the bedside they pick the cannulation sites.

I do the first cannulation talking the whole time

what I'm doing, what I'm doing, I hand it off to them

and I stand over their shoulder

and I repeat the process talking about what you're doing.

They find that after a few of those going forward, then

what I would do is I present at the bedside

and coach just talk over the shoulder.

Okay, now you're gonna this. Now you're gonna that.

Now why don't you try this?

And I've gotten feedback that that is helpful,

but getting feedback from your learners

and providing feedback from the PE

to the people teaching you is only gonna help enhance your

education program if you don't know what you're looking at,

learn how to capture an image

or a clip on your ultrasound so you can discuss

that particular case at a later date.

It's always worthwhile not to give up when you don't know,

but to ask why?

What? What is this? What are we doing next?

What are the next steps?

So I would like to say thank you very much for your time.

I appreciate you joining me in this webinar

and I hope that I've provided you with some information

that can be helpful to you.

Ultrasound guided cannulation in the hemodialysis unit is my

passion and I will continue to try to learn as much

as I can about this.

And thank you again for your time.

And I guess now we're going

to answer any potential questions that would be out there.

- Yep, that's correct. So if anybody has any questions,

feel free to put them in the q and a box at the bottom.

Looks like we've got a few coming in already.

One that came in earlier was talking about the

doppler colors.

So it says, hi Adrian with doppler colors.

What if I'm only seeing red or only blue? No mixing.

- Oh, well then you know what? You can almost assume that in

that particular access you've got the blood flowing in one

direction and usually it it is

because that particular access has lower access flows.

So we all know the average access flow that we like

to see is about 600 milliliters per minute.

Sometimes with the older individuals,

blood pressures a little bit dehydrated.

They might have lower flows

and if that's the case, you might just see the one color

because the blood is very calmly flowing up that vessel.

You might see the dual colors when you have a higher

flow upper arm access.

So that might be the reason why you're seeing

one or the other.

No matter what color is a good thing,

it means the vessel's patent.

- And there's one that says, is the ultrasound the same one

used for PICC lines?

- Yes it is.

A lot of times in a lot of facilities

and nurses use ultrasound to insert PICC lines

and it's nurses who put them in.

It absolutely is

to some degree all ultrasounds are the same,

but the probes allow you to use them for different things.

So in PICC line insertion, they tend to use the vascular

or linear probe, which is the same one we use when we use it

for guided cannulation in the dialysis unit.

- Awesome. Anybody else have any other questions?

Here's one. One thing that I've noticed recently,

since we've started using a more rapid access grafts,

you often can't see color flow in a newly placed AV graft.

I was told it's because air gets into the area

around the graft, it takes time for it to dissolve.

And of course the ultrasound can't see through air.

Do you find this happens for you as well?

- So I believe you're talking about things like the flexing

graft or something, the ones that can be cannulated one

or two days after a surgical creation.

And yes, color doppler doesn't allow us to determine flows,

but what does allow you to determine patency is the fact

that you don't see any thrombus, you see black.

And I have experienced that even in my limited contact

with those types of grafts.

And let me tell you,

we absolutely use ultrasound when we're cannulating those.

'cause you do not wanna miss an interstitial event Leaking

into the surrounding tissues can make her break

that particular graft on a go forward.

So yeah, doppler is not used in those

circumstances for that reason.

- Hey Chris, I can go ahead and take that last one here.

- Sure. - We have a question about if you,

do you mind using these webinars to teach our teams?

This webinar will be posted on our

behind the scan webinar page

that you can see on this slide right now.

And you are absolutely welcome.

Welcome to play that webinar for your teams.

- Looks like we've just got a couple more thank yous here.

So looks like that's it for the questions.

I wanna thank Adrian for coming by

and doing a great job talking about this cannulation topic.

Hopefully everybody learned a whole lot.

And if you'd like to see this later on, again, you can go

to the behind the scan webinar link that's down there.

And we thank you all for joining us.

We understand the challenges of adopting ultrasound-guidance for cannulation in the hemodialysis unit. Watch Adrienne Barrett, RN, as she provides an overview of how to perform an ultrasound-guided cannulation in the hemodialysis unit including identifying anatomy on the ultrasound screen, overcoming potential barriers to adopting this skill set, and how to add ultrasound to the “tool box” used by hemodialysis nurses.

What You'll Learn

Upon viewing this webinar, viewers will be able to provide better patient care by having a better understanding of how to:

  • Perform ultrasound-guided cannulation in the hemodialysis unit
  • Identify what you see on the ultrasound screen during an ultrasound-guided cannulation
  • Cannulate without having a second hand to stabilize your vessel
  • Utilize ultrasound to select ideal cannulation sites
  • Identify potential barriers to learning this innovative skill set
Adrienne Barrett
Presenter: Adrienne Barrett, RN
Position: Body Access / Independent Dialysis Nurse, Health Sciences North Nephrology Program, Sudbury, Ontario, Canada

Since graduating in 1995, with a Bachelor of Science degree in nursing, Adrienne Barrett has focused for 25 years on caring for dialysis patients. Her influence on successful hemodialysis practices has expanded over the years through her evolving roles in education and provincial policy initiatives. 

Adrienne is currently the Body Access/Independent Dialysis Nurse for the Health Sciences North Nephrology Program in Sudbury, Ontario, Canada, where she contributes to a multidisciplinary, patient-centered care team. Her responsibilities include knowledge sharing at symposia, conferences, and workshops, and contributing to task groups for the Ontario Renal Network.

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