Contact Sales
Duration:
Broadcast:
Topics: ICU/CCU, Nephrology, Nursing, and Vascular
Related
Subscribe

Never miss a webinar!

https://www.youtube.com/watch?v=xGaCpBe65XU
Transcript

- Hello everyone.

Thank you for joining us. We will begin in just a moment.

We're gonna let everyone populate the room

and we'll get started.

And if you're just joining us, we will begin shortly.

- Okay. Looks like we have a good group.

Welcome to our webinar on ultrasound visualization

for hemodialysis cannulation.

Before we begin, please be advised all attendees are muted.

You may type in questions into the q

and a box at the toolbar located at the

bottom of your screen.

We will conduct a q and a session at the end

of the presentation.

This webinar will be recorded

and archived for future reference.

Here with us today we have Kristen Armstrong

and Carol Stably.

Kristen is a clinical application specialist

with Fujifilm SonoSite

and she is a licensed sonographer

with 20 years of experience.

Kristen will be helping us

with some basic demonstrations today,

and Carol Stably is the director of Strategic Initiatives

for Fujifilm Sono Site Canada.

Carol is going to introduce our speaker today

and now I will hand it over to you Carol.

- Hey everyone. I am truly honored

to be introducing your speaker today.

Since graduating with a Bachelor

of Science in Nursing in 1995,

Adrian Barrett has been focused on caring

for dialysis patients for the last 25 years.

Adrian's currently the body access independent dialysis

nurse for the Health Sciences North Nephrology program in

Sudbury, Ontario where she contributes

to a multidisciplinary patient-centered care team.

Her responsibilities include knowledge sharing at symposia

and conferences contributing to task groups

for the Ontario Renal Network.

Adrian is passionate about implementing new approaches

that bring value to both clinicians and patients,

and this is why she was an early adopter

of ultrasound guidance in hemodialysis cannulation.

She continues to be a strong advocate for this practice

and she'll be sharing with you some great insights

that she's acquired by diving in Learning and doing,

and I know you'll get a lot out of her presentation today.

So Adrian, take it away.

- Well, hello everybody

and thank you for taking the time to join us today

to talk about something that's near and dear to my heart

and I spend far too much of my spare time thinking about.

So without further ado, let us begin.

So by providing you with today's education session,

I think it's only prudent for us to discuss

what we hope the learning objectives will be.

At the end of this particular educational session related

to ultrasound guided cannulation in the hemodialysis unit,

I will hope that you will be able to do the following,

first list evidence

and expert opinion supporting ultrasound use

for successful cannulation in the dialysis unit.

Second, understand what is involved in becoming proficient

at ultrasound use for cannulation.

Three, list a number of potential fistula

and graft related issues

that can be identified with the ultrasound.

And four, begin making the case

to initiate ultrasound guiding emulation at your institution

if this has not already been adopted.

Often when we perform any kind of nursing task,

it is prudent for us to understand the best practice

guidelines that can back up those tasks we perform

as it relates to ultrasound guided cannulation.

In truth, there are limited guidelines to support the use

of it, but that's just

because it's fairly new in our industry

and it's something that's building up momentum.

If we were to look at, for example, the K dokey guidelines

for clinical practice related to vascular access,

these guidelines are dated 2018.

But correct me if I'm wrong, I think the publication

of these guidelines just came out this past April, 2020

guideline 12.2 states

that K dokey considers it reasonable to use ultrasound

to help determine direction and flow

and proper needle placement and selects patients as needed

and performed by trained operators

to prevent cannulation complications.

In that same guideline, an export opinion indicates the use

of bedside ultrasound

to aid in cannulation has been associated

with increase in nurse confidence,

pay comfort, and can help determine direction of the flow

of the access.

You will notice the first one on this slide indicates it's a

guideline and if you can recall, guidelines are based on

a rigorous review

of existing research out there to support it.

So there's usually lots

and lots of research articles that will support it.

Often there's not enough research out there

to support a really good thought.

While there is research out there related

to ultrasound use, there isn't enough.

And I think in the nursing profession we need

to keep in mind that continuing research

and taking hold of research opportunities can only help

in moving our practice forward.

The expert opinion would've been based also on research,

but there wouldn't have been enough research out

there to make it a guideline.

So that's why you've got the two listed here,

a guideline and an expert opinion.

There was also within those recent K dokey guidelines,

a special discussion that stated centers

with limited opportunities for staff

to cannulate dialysis accesses face particular challenges

accessing online resources such as this education session

that Onsight is offering you today

and expertise should be considered to ensure the provision

of adequate care to patients.

I think it's fair to say that everybody's aware of the fact

that there are varying sizes

of dialysis units throughout the world.

Even if I were to take the focus

to the province in which I live, which is Ontario,

there are multiple dialysis units

and they are multiple sizes

and the infrastructure within those units varies based on

the population and the number of staff members.

So it can be very difficult to initiate the use

of ultrasound guidance when you have a really small unit

possibly have limited access to arm accesses like chills

and graft that you're going to something that's possible

to do if you decide

to make it a priority within your practice.

On further note related to guidelines,

if we take a look at the Canadian Association

of Nephrology Nurses and Technologists

or can't the nursing recommendations from 2015 state

the use of portable ultrasound for access assessment

and ultrasound guided cannulation can optimize cannulation

and ensure correct needle placement.

And I think I'm correct in saying in

that no hemodialysis nurse presents at the bedside wanting

to fail at the cannulation, we would like to have success

because frankly success just makes our day go better

and gives the patient the best outcomes.

So there are several articles

that I often have looked at related to ultrasound as

as I've been trying to figure out

how do I create an education package to support this,

how do I encourage others to use this particular skill set

and to make it a priority within their own practice their,

and I'm gonna be listing three of those articles here

that I thought were prudent.

This first one is by Kamata etal

and it essentially goes over why ultrasound should be used.

It states that patients presenting in our dialysis units

are presenting with more complex vascular accesses,

and that's happening mostly

because individuals

with preexisting comorbid conditions are living longer

with those conditions.

And when they present for creation of a vascular access,

their vessels might just barely meet the guidelines

for creation of that access.

And as a result, when they present in front of us

for their first dialysis treatment in their initial

cannulation, you're looking at an access

that doesn't make you go, yay, that's huge.

I'm gonna have no problem getting the needles in.

As opposed, you're gonna look at it

and go, oh, oh, we've got a challenge here.

So it suggests that use

of ultrasound in those circumstances can help create

positive outcomes.

It also addresses the use of ultrasound for such things

as central venous catheter insertions,

but it does address arm accesses.

That's a good access for that reason.

The second article here by So Al acknowledges that is

to support ultrasound use as guided cannulation

and they created a study to inform sample size calculations

for future multi-site trials.

So this is a good idea about formats research that's needed

to support ultrasound

and make it a standing guideline internationally if we can.

And this third article is by Carina et al.

It reviews exactly how to support competencies related

to ultrasound guided cannulation in your dialysis unit.

It says that theory plus practice with the use

of simulation learning can help have the best outcomes

and it actually lists competencies that you can try

to have your staff achieve in order

to become proficient at the use of ultrasound.

So these are some good examples if you're trying

to figure out how, how do I instill this

and how can I make this,

this practice in the nursing profession more meaningful?

So let us discuss the essential benefits of ultrasound

because of course we're only gonna use it if it will

potentially help us.

A proficient operator,

ultrasound operator in the hemodialysis unit could result in

the following, increased confidence in the nurse

performing the cannulation.

I can't tell you how many times I have presented at the

bedside of an individual who,

when I look at my daily schedule of patients

that you're gonna cannulate makes me break out into a sweat.

Somebody is on that list

who I have encountered major difficulties cannulating in the

past if I'm lucky I'm working with

and I might be able to call 'em over for assistance.

But knowing how fast paced the work is now in our units,

knowing how acute patients are in our units

and our ability to call over our coworkers

to the bedside gets harder and harder as we have more

and more to do

and the stress that we feel with increased workload,

then you add something like this pandemic on top of that,

you don't have to tell me we're all stressed out to the max.

If you can do anything to increase your confidence so

that when you present at the bedside the least

of your worries is the cannulation difficulties you might

encounter, then I say maybe it's worth thinking about

adopting this as a priority

for your toolbox skills.

So let's forget about us.

Let's just talk about first

and foremost, the patient who's being cannulated.

There are suggestions that the use

of ultrasound in the hemodialysis unit can decrease the

anxiety that the patient being cannulated feels.

And I can only imagine what it would be like

to be on the other side of the fence presenting

with a complex access in my arm

and having in my mind,

I know these three nurses have had success,

but this stranger in front of me today,

oh I'm worried.

Well if that stranger in front

of you today confidently showed up at the bedside and

and body language, you know they're relaxed,

they're like, hi, how are you?

My name is, oh, I'm just gonna use the ultrasound here.

If I saw that

and I was in the role of a patient,

I think it would actually have a positive impact.

I think that it would decrease my stress and anxiety.

And as nurses

and as patient advocates, I think it's reasonable

to suggest that we would like to do anything

that will make the patient experience better.

Perhaps ultrasound can fit the bill there

and then naturally from all of that,

if we could have less incidents of interstitial events

or missed cannulation, which can cause acute damage

to the dialysis vascular access, that's only a good thing.

Another benefit of using the ultrasound, I think I'm not

talking out of my ear here when I say

that if you have a complex ace access that presents in front

of you and then

that patient experiences consecutive missed cannulation

with dialysis treatments, there's a very good chance that

that access will become unusable while it needs

time to convalesce.

And that could result in the insertion

of a central venous catheter.

While we give time for that access to rest,

if we can avoid such a procedure

as a central venous catheter insertion,

that is one less intervention

that this patient has to go through.

And often when you're on dialysis, it's a chronic situation

and you have long-term experience

with the healthcare system, the less interventions

that we can, I found this on web experience,

Siri talking to me there.

The less interventions we can provide

for our chronic patients, the better.

So with the benefits of ultrasound,

I think your number one question might if you're not

proficient at this time,

why does using the ultrasound frustrate me so much?

It adds stress. It doesn't take away stress.

Adrian, so I I'm not buying into what you're saying.

You need to have patience with yourself. It takes time.

There's actual suggestions out there that it could take up

to 500 cann in a row

before you come become proficient at using the

ultrasound for guided cannulation.

That seems like a lot and it's,

but that doesn't mean that through

that journey you're not increasing proficiency,

increasing your confidence, decreasing mis cannulation.

It's frustrating. But I'd like to think that I'm one

of the individuals in our profession

who has obtained a certain level

of proficiency when it comes to using the ultrasound.

And let me tell you, it's fantastic

to walk into a dialysis unit, to be called to the bedside

to assist with a complex cannulation

and to not have additional stress.

I know that if I take my time,

if I use the skillset I've worked hard to to create

for myself, then I'm gonna have the best

possible outcomes that I have.

Doesn't mean I'm never gonna miss again,

but it certainly means that I've experienced a lot less

missed cannulation in my practice

and I'll take that for sure.

So we're nurses, we're not trained sonographers,

we are not using this ultrasound as a diagnosis tool.

We are using it to help us cannulate,

but that doesn't mean we shouldn't have a basic

understanding of exactly how the ultrasound works.

So let's review a few basics

of ultrasounds.

So essentially the ultrasound machine produces an electrical

energy that travels through the machine to the probe itself.

The ultrasound probe

or transducer turns this energy into sound waves

and sends those sound waves into the tissues

that the transducer is sitting on.

In this case, it's the probe sitting on the vascular access

of the dialysis patients.

The sound waves travel into the body

and bounce off of structures within the body.

They return that information to the transducer

and the transducer takes this energy

and energy back in electrical energy

and produces an image on the ultrasound machine.

So essentially it's taking a 3D situation

and turning it into a 2D picture

that can provide us with information.

Here I have an example of what

a cannula can look like inside of an access

in this particular circumstance, this is a Teflon cannula

or we call them super calf in a fistula.

There are three different areas,

three different words I have on the screen here, hyper coic,

koic and hypoechoic.

And you might see these words used

regularly when you're looking at ultrasound reports.

I don't use them when I am charting

and reporting on my experience with cannulating accesses,

but I like to understand how ultrasound works

and that's why I'm introducing it here in this

in this circumstance.

So you can see I've got arrows pointing to, for example,

hyper coic structures.

That's structures within the arm

where the sound weights bounce off very easily

and they tend to produce a bright white image.

So the cannula is very visible here, as is the anterior

or back wall of the fistula.

This was a well-developed fistula

with a really thick vessel

wall and that's why you can see it.

Well koic are structures

through which sound waves travel easily

and in this circumstance it's pointing at the blood

that's actually flowing through this fistula.

The blood is absorbing the sound waves

and it's traveling through the blood very easily.

I hope. Kristen, you can correct me if I'm making any

mistakes here with my explanation of ultrasound physics

and then hypoechoic.

The sound waves tend to bounce off,

but you don't get a very bright white image.

You might get varying degrees of gray scale,

thus your image turns up black, white and gray imaging.

When it comes to the type of ultrasound transducers

or probes that matters, you need to have the correct one

for the ultrasound imaging that you're going to be doing.

So in the case of vascular accesses

and guided cannulation in the hemodialysis unit,

a linear array transducer or probe is what is needed.

And this is the probe used for venous cannulation.

So not only does it, you get used

for cannulating arm accesses,

but you might find some

of the doctors in your practice might use it for cannulating

femorals or jugular veins.

This of course is an image

of the transducer we use in my unit.

So let's get right into the nitty gritty then

because the slide says we should.

So using the ultrasound for cannulation,

how do you perform a cannulation using the ultrasound?

Okay, that's a loaded question I've got here on the right

of this particular slide deck, a couple of images about how

to hold the probe orientation of the probe.

The image on the left shows a ultrasound probe in

in a linear fashion here.

So what it is is a longitudinal view of a vessel That tube

underneath the probe is indicative of a vessel.

That blue rectangle

underneath the probe shows the area in which the sound waves

travel out of the probe

and that area is only about thickness of a credit card.

So when you can hold your probe in this way when you're

cannulating or you can do

what is called a cross-sectional view,

which is on the right hand side,

the image on the right hand side that is holding the probe

so that it's, it's looks through the vessel itself.

Almost like how when you slice a loaf

of bread you can see the inside.

That's what a cross-sectional view does.

Whereas a longitudinal view would be cutting the bread

completely the wrong way, which you're not supposed to do.

First of all, your children would

probably give you trouble for it.

But regardless

what I have here is more explanation related

to a long access

or longitudinal view using an ultrasound probe.

So I took the image from the previous slide,

I have it on the left in the middle I have our lovely sono

cyte model showing us

how she holds the probe longitudinally when she's got,

so she's got in her right hand the cannula, the needle,

and in her left hand she's holding the probe

and that's how she holds it to get a longitudinal view.

On the right hand side of this slide, you see an image

of actually the longitudinal view of a graft

graft show up in a unique way

that their walls appear to be double walled.

So that's how you know when you're looking at the ultrasound

that you have a graft that you're looking at.

It can help identify the type of access that you're going

to be cannulating or the one that you're assessing

when you do a short axis or cross-sectional view.

I have taken the picture from the previous slides

and shown how the probe looks and a cross-sectional

and once again, our lovely model is showing us how

to hold the probe to get a cross-sectional view on the

screen of your ultrasound machine.

So she's got in her right hand the 15 gauge needle

for cannulation, the left hand she has the probe

and here we have on the far right of our slide deck,

the image of a cross-sectional view

of a fistula in a patient's arm.

So this is actually somebody who volunteered to allow me

to take pictures of their arm with the ultrasound.

So hopefully you have an idea of the difference between

what cross-sectional and longitudinal views are.

The orientation of the probe matters

using the ultrasound for cannulation.

All right, so first of all, you gotta get the ultrasound

to the patient's bedside

and I encourage you at this particular point in your day,

I recognize you're busy.

I recognize that dialysis nursing can often feel like an

assembly line thing.

You've got patients waiting to be put on

and they're glaring at you

because you're not moving fast enough

and you're taking your time well, you know what,

it pays to take your time.

When it comes to ultrasound use for guided cannulation,

I recommend that you take the time to move the equipment.

You might have limited capacity to do so

because you have very small area,

but still take the time, place the ultrasound in a way such

that when you are cannulating the patient's arm,

you simply have to do a very small turn of your head

to view the screen and then back to the arm.

As opposed to having the ultrasound

behind your shoulder here where you're doing this

to look at the screen and then back at the arm.

First of all, that can be very physically

uncomfortable for you.

When you add physical tr stress such as creating your neck

to look at a screen, you're gonna add

to your own personal stress during the process.

But if you set it up so that there's minimal of movements

and that you keep your own physical status relaxed,

this can help you manage it in a more positive way.

So please take the time to move the chair, move the bed,

move the machine, the bedside table and set it up naturally.

Sometimes that means asking the

patient to get outta the chair.

Sometimes that's not possible

because they're not mobilizing well.

But do the best you can

to set it up in the proper ergonomic setting.

So using the ultrasound for cannulation, in order to do so,

you need to add gel to your probe.

But there's a lot of infection control departments

and facilities that have indicated rightly so

that there is a proper way to manage the probe

to reduce infections between patients

or cross-contamination between patients.

And that's the use of a probe cover.

It is recommended that you use a sterile probe cover as well

as sterile gel.

I have found personally in my practice to do this, put gel

inside the probe cover, then put it on the probe.

What you're gonna have to do afterwards is add more gel

either onto the patient arm

or onto the top of the probe cover.

If you don't have a lot of gel between the probe

and the probe cover, you might find that the image produced

by the ultrasound machine is is not clear.

You you, it looks like you got blank spaces

and it's not showing the circle

that's supposed to be your vessel.

You can't see it very well.

It could very well be related to the gel that you're using.

If you have sterile ultrasound gel, then you don't have

to worry about the gel covering the portion of the skin

that you're going to be cannulating through.

It will not contaminate 'cause it's already sterile.

If you don't have access to sterile ultrasound gel,

you do need to keep that in mind

because you're going to be maintaining

as septic technique during cannulation.

You're gonna have to be careful not

to let the gel cover the insertion site if that's the case,

it's always prudent to know

what your particular facilities infection control parameters

are when it comes to the use

of the ultrasound in the hemodialysis unit.

So it's not simply picking up the machine

and running with it and going,

it's having robust conversations

with other departments about what's the proper way

to use this so

that we don't put our patients at risk using it,

using the ultrasound for cannulation.

So you will notice

that if you do the previous things I suggested

and you've got a lot of gel everywhere,

you're actually gonna find that the top

of the screen is not indicative of the the surface

of the patient's skin on their arm.

In fact, the gel is creating a distance so

that this top arrow indicates where the top of the images

and the bottom arrow indicates where actually the surface

of the patient's skin is.

And this is gonna matter if you are determining the depth

of the vessel, which matters in the angle in which you

approach with your cannulation.

All right, how you hold the ultrasound for cannulation?

So I am going to, at this point, I've got a picture up here

of myself holding a probe on a patient's arm.

I like to have portions

of my hand touching the patient's arm,

but I'm gonna refer to Kristen here to talk

to you about the proper way to hold a probe.

Are you there Kristen? You ready to jump in?

- Hello? I don't know if you can say Okay. Hi.

So a few things about the probe

and Adrian's got a great picture up there.

You're going to use a linear probe.

So this is also a linear probe.

The size of the footprint may vary depending on

what probe you have or what system you have.

The probe has a few features as well.

So on the end of the probe you have the lens,

this gray area.

Many people think that the beam comes outta that entire size

of the gray area

but it doesn't the the width of the probe, the width

of the beam is actually about the

thickness of a credit card.

So how you aim the probe is gonna become important

and I'll talk about that in a second.

The other thing you need to know if you can see it here,

not sure on the edge of the probe we have a little bump

that's an orientation indicator.

You may have a triangle, a square, a dot, a bump,

whatever you have that indicates which direction your image

is going to be displayed.

So we like to keep that dot

towards your left side if we're looking in short access.

The other thing we have on the probe is this

line down the middle.

The line down the middle indicates the direct

center of the probe.

So when Adrian talks about cannulating,

she's gonna show you a guide that can come up on the screen

and that will indicate the direct center on the

ultrasound screen itself.

So when you hold the probe, a light touch is most important,

especially when you're doing vascular access.

If you push too hard, you're gonna collapse your vessel.

So if you, the closer you hold down to the end of the probe

and as Adrian's saying, if you can at least anchor one

or two fingers on the patient's skin,

it will keep the probe from drifting off

to one side or the other.

It also allows you to hold the probe lightly so as not

to compress the vessel

and it allows you to turn the probe in different directions

without moving around too much.

So if we can keep at least a couple fingers on the patient,

one or two fingers, we also wanna make sure

that you keep the probe perpendicular.

So if you think about the beam coming outta the end

of the probe and it's the thickness of a credit card,

you're going to see directly beneath the probe.

If I now angle my probe this way,

then I'm shooting the out

and I'm not seeing what's directly beneath.

So you can imagine if I'm putting a needle in,

if I'm putting the needle in this way, I'm projecting it

farther to one side.

If I'm put putting my needle in from this side,

I may never actually see the needle.

So if I am holding the probe this way

and my needle is coming in here,

I may never catch up with the beam.

Okay, if I'm angling this way, I'm seeing the

the shot hilt of the beam, not instead of the tip.

So important to keep your probe straight up and down.

So what you're seeing is the tip

of the needle coming in directly under the

probe in the relation to proper relation to the vessel.

- Back to you Adrian.

- Thank you so much as always.

Kristen has been a wonderful resource in my program when it

comes to learning about ultrasound

and I'm glad she was able to step in and explain that

'cause she did it a heck of a lot better than I can.

So holding the probe matters. How you hold it matters.

Essentially when you've got your probe lined up

and you've got that arrow on the probe

or the line on the probe, it is going

to be in the exact same spot

or it's actually gonna line up with this guideline

that shows up on your screen if you ask it to.

So in this particular circumstance on this

particular model, you have a choice of using a center line,

which is a dotted line that goes down the middle

of the screen or the middle of the probe itself or guide.

We use the guide.

The guide falls down the center of the probe

and it actually has specific distances

between each of the dots.

The image itself has a depth of,

if you look at the bottom right hand side of this image,

2.6 centimeters.

My apology to our American joiners, we like

to use a metric system here in Canada.

So I speak in centimeters a lot

and hopefully that works for you.

It's just over an inch, right? Right, I think so.

So in between each of those dots is five millimeters

of distance or half a centimeter.

And this can allow you to determine that approximate depth

and approximate diameter of the vessel

that you are cannulating.

And like I said previously, it's gonna matter

because if it's deep

but you're gonna change the angle of the approach

for cannulation and if it's shallow you're gonna do the same

change the angle of approach.

Your ultimate objective is to make the vessel

as big as possible, a big circle right in the middle

of the screen because your objective is to get the tip

of your cannula in the center of the vessel.

And in order to do that you

need to know where the center is.

By lining up the vessel with the center line

or guideline, you're lining it up with the arrow

or line on the probe that you're using.

So step one, get the vessel in the middle of the screen.

Now I'm going to show you this slide here which talks about

how to actually cannulate the physics of walking it in.

Essentially what happens is this gray bar here is

representing a cannula

or a needle you're using to cannulate.

This blue bar represents the ultrasound

waves, what the probe is sending down into

the into the skin.

So when you cannulate, you're going

to use a method of walking it in.

This is something that I have shown individuals in my unit

to use and I feel it's one of the best ways

to cannulate an individual.

So the first thing you're gonna do is you're gonna take

that cannula and you're gonna advance it

until you feel that it's in.

It's going to be directly underneath the probe.

While you're doing this,

you are simply looking at your probe

and you're aiming for the arrow.

When you feel you have reached this objective,

the cannula directly under the probe,

you will turn your head and watch the ultrasound screen.

You are now going to continue watching the ultrasound screen

and move your hands independently.

The first thing you're going to do is advance the

probe up the arm.

So let us say we have an individual with a forearm fistula.

The anastomosis is by the wrist

and this fistula ha takes a lovely straight pathway

all the way up to the elbow.

So we're using the ultrasound to cannulate.

We've already introduced the cannula into the vessel

and now when we turn our head, the cannula shows up

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

Well now we wanna advance it ensuring

that the tip stays in the center of the vessel.

The first thing we would do is advance the probe

until we lose sight of the cannula.

We then bring the cannula back into the image on the screen.

This is why you're only watching the screen.

You are moving your hands in very small increments,

millimeters only fractions of an inch.

You're gonna move the probe till you lose sight

of the cannula again and bring it into the field of view.

You might at this point have

to make some corrections at your angle

because if you continue on the same angle,

you might hit the anterior wall or back wall.

You wanna aim for the center,

the tip has to be in the center.

That's essentially the basics of how to walk it in.

Now thankfully Kristen was lovely enough

to create this video not only

with the ultrasound image on the right hand side,

but with herself using the probe for cannulation.

So this is a live image she's capturing on the left hand

side you will see the cannula there approaching the vessel

and she's moving her probe only incrementally.

So if you watch her hands, very small movements are used.

She's actually going to change

and do the longitudinal view here.

And the nice part about a longitudinal view is it you can

watch yourself and you can avoid back walling.

You're only gonna get a superior image like she did if

you're in the center of the vessel.

If you're off to the side

and you try a longitudinal view, your image may not be quite

as clear and and you get confused as to about

where your cannula is.

So try the cross-sectional method of walking it in

and then when you become proficient

and you're confident that your cannula is in the middle

of the vessel, you can do a longitudinal view for advance.

But if you can in some

circumstances use the cross-sectional four cannulating

and then when you're done do a longitudinal

to check placement of it.

I hope that makes sense to you.

Alright, so once again I'm gonna show you a live video

of cannulating fistula.

In a patient of walking it in, you will notice

that you lose sight of the cannula, then it comes into view,

you lose sight of the cannula.

It comes into view. If we kept the probe still while we were

cannulating the the access, we would be watching the tip

and then we'd only be watching the shaft

of the cannula itself.

And if we don't check where that tip is on a regular basis,

chances are if you continue in that same direction,

you're gonna back wall, have an interstitial event,

cause acute injury to the access.

So the number one question you have

to ask yourself is, where's my tip?

Where's my tip? Confirm. Confirm reconfirm.

That's your objective. Alright,

so those are the basics of how to use ultrasound

for guided cannulation.

Trust me, it can be very frustrating

and I would not recommend

that you start using it on somebody

who has a complex access.

If you have the luxury of cannulating a patient

that you have not missed on before

or that you very rarely miss on

and they have a nice big access, that's who you need

to start your practice on the for sures.

The patients who don't make you sweat when you see them

because you can cannulate with your eyes closed,

use the ultrasound with them, get used to that process so

that when you have a complex access in front of you,

you feel a little bit more confident about the actual

physical skillset that's needs to accompany that.

Once you've passed that point,

or perhaps you wanna use the ultrasound not

for guided cannulation

'cause you don't quite feel confident enough,

you wanna have more simulated learning sessions.

Before you do that you can use the ultrasound

to assess accesses.

And a lot of times what I get

with people are becoming more comfortable

and proficient with the ultrasound use is questions about

what is it that I'm looking at.

So what I'm gonna do in this next section is review a few

things that you might be looking at

so you know how to identify them.

We're gonna look at how to identify fistula versus a graft,

and we've kind of covered that already,

what a pseudo aneurysm looks like.

What acute injury presents as what a branching vessel looks

as looks at and how do you capture the diameter

and depth, the exact numbers of measurement

for particular accesses, especially if you're trying

to determine if the access is mature enough for cannulation.

So this first slide shows image on the left of a fistula

and the image on the right of a graft.

Now I think you can safely assume

that the image on the right shows a pristine graft

if you're lucky enough to have a patient

who has a vintage graft.

And in our unit we actually have a patient who has a graft

that is 19 years old.

Let me tell you, her graft doesn't present in this way.

The anterior wall or back wall

or posterior wall back wall does present

beautifully pristine.

But because she's had multiple cannulation,

there's actually a breakdown of the PTFE material

that is a graphs that we use in my particular program

and it almost looks like the top wall there,

the the anterior wall is is chewed up.

So, but that's the basic differences

between a fistula and a graft.

Areas of acute injury.

I took this picture of a patient's access one treatment

after they had experienced a pretty substantial

interstitial event.

They presented for dialysis with a lot

of bruising on their access arm and some tenderness.

If you take a look at this image, the arrow is pointing

to the swelling

that's happening within the vessel from the injured area.

What happened was a back wall event,

they injured the back wall and it is now inflamed and emus.

So the arrow itself actually follows

where the injury is.

If you use the ultrasound to assess an access like this

that presents as bruising,

what you could potentially do is avoid the areas

of acute injury in that access that are already there.

If you can find an area in the access

that doesn't have this acute injury, that's

where you would choose to cannulate one treatment

after an interstitial event.

In this particular image I have a artery in a vein

and the vein is top and the artery at the bottom.

What I did with the probe,

it is I pushed down on the actual patient's arm

and I compressed or tried to compress the vessels.

A fistula made of a vein is easily compressible,

whereas the artery not so easily compressible.

And if you continuously look at this image, you will notice

that the artery is more pulsatile than the va.

The vein is, and that's how you would identify

between the two structures.

- Once again, here's

of the access given

- Time, these areas of injury will repair themselves,

but I do recommend not cannulating in these areas

of injury if you have the option to not cannulate there.

Here's a simple longitudinal view

of a fairly aneurysmal access in my dialysis unit.

You will see that as the vessel goes from left to right,

it has a fairly small moderate diameter on the left hand

side and the diameter just increases naturally.

What happens with repeated cannulation in the same site is

we break down the integrity of the vessel wall

and we get enlarged areas of the access.

And on the right hand side we're approaching an area

of frequent cannulation on this patient's access.

Here's the picture of an actual collection

of fluid on the top of a vascular access

that had experienced acute injury during cannulation.

So it kind of looks like a little bit of active fluid.

Here is a fairly

damaged wall of a graft in a patient's arm.

You can no longer discern the double wall on the top there.

It's, it's non-existent.

It's been chewed up by so many cannulation.

This one's interesting. You don't get a lot of stents in my

dialysis unit, but this one I was able

to capture a cross-sectional image of

what a stent looks like in a vascular access.

A lot of conversation going on

between the collaborative in my province about should you

cannulate a stent or shouldn't you

because stents tend to be made up of PTFE material,

the same stuff that graphs are.

But there is some question that if you put a needle

through the infrastructure

or the scaffolding of a stent that you might damage it

and then that no longer, it no longer serves its purpose.

So you have to follow your own unit protocols as it relates

to stents, but it's good to be able to identify

where they are on the access.

This is how a stent would present at a cross-sectional view,

and this shows you how a stent would present in a

longitudinal view.

Here is the use of colored doppler.

You see basically two colors, red orangey color

and blue color.

A lot of times as nurses as we might not identify that

as arterial flow versus venous flow,

but the color differentiation

with an ultrasound is simply due to the fact that one color

captures blood flowing towards the probe

and the other color captures blood flowing

away from the probe.

We would use this particular color

doppler if we suspected that an access was close

to being clotted or was clotted.

By using this we can confirm whether

or not there is actual flow through the access

and it'll help you determine like you using the ultrasound

is never going to replace the physical assessment

that you do for an access.

Look, listen, feel, look, listen, feel is what you do

before every cannulation.

You may choose to bring the ultrasound as one of the tools

that you use in that look, listen, feel, assessment.

It would come in the look part and you could,

after you've assessed the access, you might determine

that the thrill isn't present, you can't hear a buoy,

you might want to use the color doppler to confirm

that flow is no longer happening.

Through that access then you can avoid cannulating an access

that is thrombo and instead you can move

to next steps is can we do something, some kind

of intervention to assist with this thrombo access.

Sometimes when you are using the ultrasound at the bedside,

you might come across a structure or something that you see

and you have problems identifying exactly what it is.

You'd like to have a me meaningful conversation

with your coworker or perhaps the educator

or mentor in your, that you have access to in your unit

who is proficient at using ultrasound.

Well in this particular circumstance, you might want

to capture a picture so that you can refer

to it later in a conversation.

And you can do that by simply in this particular model

of the sauna site, pressing the camera button

and it'll capture a picture of

what you're seeing on the screen below, which is a picture

of a video camera.

You would hit that

and it would capture a video clip of a limited duration.

Kristen, I'm going to get you to discuss the fact

that while this may not appear

to be an option on your model when it comes to sauna site,

sauna site use, there are various models,

but you still have the potential to use this image

and video clip option.

- Yeah, definitely. So for those of you

that have the newer S two ultrasound, which is

what Adrian's showing you here, you'll see that camera

and you'll see the clip option.

The clip option can also be preset.

Get anywhere from two

to 60 seconds on your clip if you choose.

For those of you, a lot of people in Ontario at least have

the older version of the S model, which is the SC

or the S nerve, something like that.

It's a brown flat screen with lots of buttons on the side.

In that case you don't see the camera

and the video camera readily apparent.

But along the bottom of the monitor you should see

something, a freeze button or and a save button.

So if you want to measure

or capture an image, you can hit that freeze button,

it'll hold your image still

and then you can hit the save image

and the image will be saved to the ultrasound system.

If you have the laptop style system from Sono site,

you will see the camera button and you'll be able to save.

Or you'll have a save image button also along the

bottom of the machine.

Other, other manufacturers will also have this feature.

You just have to check with your application specialist

or your your rep to see

how you can go about saving the images.

You can pull them up from the patient review button

and if anyone has any specific questions about recording

saving images or where

to find them once you have saved them,

if you put a question into the q and a box

and then I can try and answer specifically to your model

how you can go about doing that.

- Thanks Kristen. Is that good, Adrian?

Yeah, that's perfect. Thank you so much. As always.

She's an excellent resource.

She's the reason why I was able to capture images

that I've embedded in this actual slide deck.

I hope that they've been helpful.

I continue to capture these images

and I use them within my own facility

to help support education related

to ultrasound guided cannulation and hemodialysis unit.

So if you are using the ultrasound, you have the luxury

of assessing an access

before it even needs to be cannulated.

Let's say you have somebody presented for dialysis

with a dual access, they have a central line in

and they have an access that's waiting for

to be ready for cannulation.

You should take advantage of that

and take the time to assess that access.

So you're using the ultrasound not for cannulation,

but just to look at the vessel.

You'd be surprised at

how engaged the patient becomes in what you're looking at.

And if you have the capacity to briefly explain

what you're looking at, then they become even

more interested.

So often when it comes

to determining whether an access is mature enough

for cannulation, we used to follow the rules

of sixes from the fistula first program.

New K doki guidelines have kind of changed it briefly.

They do support the idea of the rule of sixes,

but they don't make it a guideline anymore.

They'll say, for example, that your access needs

to be equivalent to

or less than five millimeters below the surface of the skin,

which is half a centimeter and it should be just as wide.

So in this particular circumstance, I took the time

to measure the diameter

of somebody's existing well matured fistula.

And on the bottom right hand side,

the caliper measurement tells me

that this vessel is 1.23 centimeters in diameter.

So you can use the ultrasound to get exact measurements,

not only of the width or the height of the vessel,

but the depth of the vessel from the surface of the skin

to the top of the vessel itself.

So becoming proficient at ultrasound use,

I wish I could tell you

that I have wad my waved my magic wand in all viewers

of this education session will now go out into the wild

and cannulate like superstars.

I hope you do and I hope you already have

the capacity to do that.

But I do recommend, like I mentioned earlier,

get comfortable with handling the equipment

without cannulating.

At first, use any type

of simulation education that you can.

Blue phantom, a fake arm for cannulation so

that when you're cannulating

and getting used to how to hold the probe,

you're not actually putting a live patient through that.

You've got something that's simulated to use that

you can use the ultrasound to assess the pathway, the depth

and the diameter of the vessel

to confirm cannula placements.

So you can use the ultrasound

after you've cannulated, just, you know, I think I got that.

I think I nailed that cannulation.

I think the tip of that cannula

is in the middle of the vessel.

Why not use the ultrasound to see if

that actually was achieved?

Try to focus on watching the screen while you move the probe

up and down the arm to become,

to become more comfortable at performing this action.

In this particular slide,

this is me running a slide up, a patient's access.

They had a forearm fistula, so I went from just

above the anastomosis to almost the elbow.

And you will see there's an actual capture

of a branching vessel right there on the right hand side.

It looked like a, a road going off to the side.

That's what a branching vessel could look like.

It can also look like a dot that leaves the big dot

and then goes off to the side.

That's what a branching vessel can present

as when you're looking at it in an ultrasound.

Allow yourself fish sufficient time

to perform these initial guided cannulation.

Prepare your patient by explaining your plan

and obtaining their consent to this plan.

They might be completely frustrated

because of things that happened during their day

and their ride was late and they're getting on late

and they don't want that to be used.

We kind of, you know, we have to respect.

If they say no, then no, it is.

Use mentors within your program to coach you

through the guided cannulation.

This might be educator who's rolling out the ultrasound.

It might be somebody who shows proficiency, who's a front

frontline bedside nurse.

It could simply be that you don't have mentors in your unit.

Well then engage in conversation

with somebody else who's interested in becoming proficient

at the use of ultrasound.

And you'll find that if you have somebody else on your side,

you're gonna have interesting conversations.

Reach out to all the resources you have access to

to answer your questions

and expect to perform multiple successful guided cannulation

with coaching prior to performing independently.

If you have that luxury in your program,

whenever possible, ask somebody to coach you through.

You're the one operating all of the equipment,

but you have somebody behind you who's gently reminded you.

Okay, look up at the screen now, look down at the arm.

Oh, you're drifting.

You're not holding your arm still the probe is

moving across the arm.

You gotta remember to hold that as still as possible.

Coach gently don't bark out orders

or reach over around somebody to press buttons.

So essentially that's the end

of our education session related

to guided cannulation in the hemodialysis unit.

I hope I've had some value added to the information related

to, to this particular skillset,

and I'm more than happy to answer any outstanding questions

that you might have at this time.

- Thank you Adrian, for an excellent presentation.

I've learned a ton. So we will go ahead

and take some questions in the q and a box now.

And Carol, I will turn it over to you.

- All right, I'm here.

So Adrian, question about if I, I happened to,

it says I happen to have a new fistula that appeared

that two vessels were overlaying one another

and when I checked the color mode,

the top one was mainly blue

and the bottom vessel has a mixed blue and red color.

How do I interpret this? Ah,

- Okay.

So where you've got the mixed color,

you can just assume there's higher flow,

more turbulence happening.

I don't know if that question leads into the next question

of which one's the actual fistula.

Which one is the actual vessel that I'm aiming for?

You might be looking at a vein and an artery.

It would help if you have the capacity to follow

that vessel from the anastomosis all the way up the arm in

general with forearms and upper arms.

The cephalic vein is what's used as the primary vessel

and it tends to run fairly midline.

It can slightly go lateral and medial based on the patient.

But if you're having problems identifying which one is the

fistula, which one should you be cannulating, you need

to call somebody in with a little bit more experience,

a sonographer, your nephrologist, a radiologist,

your access coordinator to see if it can help you

with identification there.

But that, that's a really good question.

I hope I answered part of it.

- All right, well we'll see if we have a follow up here.

The different one for Adrian, again,

being an experienced user of ultrasound,

would you personally support the idea

of ultrasound cannulation being considered a best practice?

- Oh, oh yes. I would.

I can't tell you how it has changed my own practice

and confidence levels, but when I have individuals in my

unit who show proficiency, their ability

to confidently move forward and to have

and create a positive patient experience,

decrease interstitial events,

decrease patient anxiety, increased comfort levels

of the patient during the dialysis process,

all these three things

that impact the patient in a positive way indicate that yes,

indeed this should be part of the best practice.

But you are gonna get a variety of people

who will argue with you on that.

I most definitely endorse it as such.

- Excellent. Alright, another question.

When cannulating an AV fistula,

will the blood return come back quickly thinking due

to arterial flow in there?

What happens if I cannulate

and then lose the blood return? Hopefully

- That, okay, so okay, I, I'm assuming you're talking about

the flashback that you see in the hub of the needle

after you cannulate.

And that's solely dependent upon the flows within

that access.

If you were to compare a forearm to an upper arm in general,

upper arms tend to have higher flows,

so you would get more flashback.

When you cannulate somebody with a low flow access,

there is a chance that you will not see flashback,

but that does not mean you're not in the vessel.

It simply means that the flows through that access are low.

You could be looking at a sweet 90-year-old woman

with a blood pressure of 80 over nothing

and don't expect

to have big flashback when you cannulate her.

I hope that answers that question.

- Cool. Oh well I like this one.

Your presentation is fantastic and we teach the same way.

Is it possible to have access to this presentation

to show it to our dialysis nurses?

- Correct me if I'm wrong,

but we're planning on having our lovely Laura edit a

recorded option of this webinar

so it can be accessed by people.

- Yes. Yes.

And you can see the link on this last slide here,

the secure dos on the site.com, behind dash the scan.

It'll be posted there hopefully by the end, end of the day.

Great.

- Alright, I have questions.

A couple questions on how, how do you turn on the,

the needle guide?

- Ah, the guideline down the middle of the screen?

Well, it's dependent upon the model that you do have.

You're either going to use guideline if you wanna have

distance between the dots captured

or you can use center line.

So simply pressing that button engage starts it

and pressing it again stops it.

You will find that if you, correct me if I'm wrong, Kristen,

but if you turn it off,

when you turn the machine back on again, it won't be there.

You have to turn it on. Is that right?

- So the guide will stay on no matter what.

Even if you turn the system off, if you do change probes

or if you have a hard reset of your system,

the guide will go away.

I see one of the people who's asking about the guide has the

sono site edge.

If you have the Sono site edge, then you have to go

to page two of the soft keys.

So when you're looking at the monitor underneath,

there will be a list of tabs.

The far right tab says page one of two.

You're gonna push it and get to page two of two

and then you'll see the button for center line

and you can turn the center line on that way.

- Thank goodness for you Kristen. Thanks.

- Okay, so another one for you probably, Kristen,

if our facility decides to purchase Asana site, what kind

of training and assistance will the company provide?

- So when you provide, when you purchase Asana site,

I know from my experience, I go and put the system together.

I'll give some training to your biomed on how to look

after the system and then generally, we'll, we'll come up,

show you how to use the system.

We do have Phantoms available.

We can do some workshops on Phantoms

and I think Adrian will tell you we're, we're,

we're pretty accessible and we do come back time

and again if you need us.

- Yes, a lot of my front line,

my frontline bedside nurses will call Kristen

directly instead of talking to you.

- Alright. And we're, we're happy to help.

We do not, we're not nurses.

I will, I will just say that we are not nurses,

so we will not cannulate actual patients while we're there,

but we are happy to, to bring the phantoms

and get you used to using the ultrasound

and get the needle coordination on a phantom.

- Laura, I just have a question for you.

If we don't get to all these, all these questions now,

will it be possible to

get them addressed after the fact

- Or how Absolutely.

You, you actually just read my mind, Carol.

I can see a number of questions in here.

Luckily Zoom saves the questions in the q

and a box so we can reach out to people individually

with their answers 'cause we are at the top of the hour

and I do wanna be respectful

of Adrian's time since she's given us

so much information today.

So why don't we do that and go ahead

and close out the webinar

and I will make sure these questions are all saved.

And those of you who have asked questions

looks like there's only one anonymous one.

Geez. Yeah, we will just, we'll post the recording

of this afterwards

and we will reach out to the questions

that are still in the q and a box here.

So for one more minute go ahead and answer, enter your q

and questions in the q and a box

so we can make sure we capture those.

But Adrian, Carol, Kristen, everybody, thank you so much

for a fantastic webinar.

This was was exceptional. Thank you.

Adrienne discusses the value of becoming proficient at using ultrasound for guiding hemodialysis cannulations. The presentation covers current evidence and expert recommendations for using ultrasound to increase clinician confidence, reduce patient anxiety, and reduce risks of adverse events during the cannulation process. She provides an overview of how ultrasound works to allow visualization of key structures and guidance of the insertion, and recommend steps to take to increase the rate of adoption of ultrasound in the dialysis unit.

What You'll Learn

  • How POCUS results in safer cannulation
  • Tips to become proficient at using POCUS for cannulation
  • Which fistula and graft-related issues can be identified using ultrasound
  • How to initiate ultrasound-guided cannulation within your institution
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.

Show more
Related

This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.