It is critical that clinicians follow—or, at the very least, are aware of—their centre’s policies regarding cannulation practices. This message was delivered by Deborah Brouwer-Maier (Transonic Systems, Ithaca, USA) during a presentation at the 2022 Vascular Access for Hemodialysis Symposium (9–11 June, Charleston, USA), who also addressed challenges in self-cannulation and asserted: “We have to stop thinking about how we do it, and we have to start thinking about how we would do it if we were that patient in the chair.”
Addressing an audience largely composed of vascular surgeons, interventional radiologists and nephrologists, Brouwer-Maier said: “As physicians, most of you have the ability to do what you think is right based on your medical judgement. As a nurse and a patient care technician, I must practice under the policy and the procedures of the facility that I work at—I do not have the autonomy to go outside of that scope.
“I am depending on corporate and local hospital policies, and the physician order, to allow me to practice. Patient care technicians practice under my nursing licence because I am overseeing them, and that is why the policies and procedures are so important. If you have not reviewed the cannulation policy of the facilities that you are sharing patients with, I encourage you to do that.”
Here, the speaker reiterated that she cannot deviate from these policies, but detailed how clinicians can go about initiating change if they want to do something differently in their practice. “You have to get the specific policy updated—you must go to the local governing body for the dialysis facility and get the new policy fully approved,” she said. “You can alter a corporate-level policy at the local level. A medical director has that right.”
Brouwer-Maier also emphasised that there are several significant practical differences between in-centre access cannulation, which is performed by a healthcare professional, and ‘self-cannulation’, whereby the patient has to needle their own access—often because they are dialysing at home. “In centre, the staff member can use both hands, they are at a different position and a different angle, and they can visualise it differently,” she said. “The self-cannulator has to cross their own body to cannulate and do everything one-handed, including taping and needle removal. There is also the issue of feedback: when I cannulate, I do not know if I am infiltrating until the patient tells me they feel pain. A self-cannulator feels that immediately.”
Approaches to needle taping should be covered by the aforementioned policies, Brouwer-Maier continued. Due to the fact that taping techniques vary by facility, an American Nephrology Nurses Association (ANNA) taskforce convened in 2020 to update existing information and resources relating to venous needle dislodgement and access-bloodline separation. And, while this taskforce identified five standard ways to tape, Brouwer-Maier noted that, “if you are going to do this at home, you probably cannot use the same technique that is used in-centre”. Similarly, she informed the audience, distinctions between cannulation methods like the rope-ladder and buttonhole techniques should also be outlined in the facility’s policies and procedures, adding: “Area puncture is never an appropriate cannulation method.”
Another important consideration relates to device-created arteriovenous fistulas (AVFs), she stated, as the cannulation zone is in a different location for fistulas created using the Ellipsys (Medtronic) or WavelinQ (BD) systems, when compared to more traditional, surgical AVFs. “If the patient is dialysing with their arm out […] and they are trying to do things one-handed, including responding to the dialysis machines, we need to take care to place needles in such a way that they can have some arm movement,” Brouwer-Maier continued.
The speaker concluded by outlining key dilemmas for clinicians to consider regarding self-cannulation: “Can the patient or their care partner see the access properly? Are they able to determine the angle—if you tell a patient 20 degrees, do they really understand what 20 degrees is? And, the big problem with cannulation when you are first learning is potentially applying too much pressure to the needle. It needs a light touch, and that is hard to see when someone else is cannulating.”
While she also noted that cannulation is “a really hard thing to learn”, Brouwer-Maier highlighted a handful of innovations that can help make patients’ lives easier, including tourniquets that are intended specifically for one-handed cannulation, small clips for holding the needle in place, and even commercially available clothing designed with zippers or holes to improve access to the cannulation zone.