HD-CL-003 · Vascular Access Management (UPDATED)

Vascular Access Management: Assessment, Cannulation, and Complication Prevention

Policy HD-CL-003 · Hemodialysis Unit

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To establish a comprehensive, evidence-based program for the selection, assessment, cannulation, maintenance, and monitoring of all hemodialysis vascular accesses to maximize patency, minimize infection, and reduce complications in accordance with KDOQI 2020, CDC 2016, and MOH-Jordan Standards 2023.

2 Scope

Applies to all physicians, registered nurses, dialysis technicians, and vascular access coordinators involved in the care of hemodialysis patients with AVF, AVG, or central venous catheters CVC.

3 Definitions

AVF native vessel anastomosis (preferred) AVG synthetic graft CVC central venous catheter Fistula First national initiative Physical Exam Look, Listen, Feel Qa access blood flow (mL/min) Steal Syndrome hand ischemia

4 Policy Statement UPDATED

Update 1.1 Access hierarchy & CVC reduction

AVF > AVG > Tunneled CVC > Non-tunneled CVC. CVC use discouraged.

Explicit hierarchy with targets: AVF >68%, CVC <10%. CVC removal within 30 days of AVF/AVG maturation. All patients with CVC >90 days require documented vascular review.

Rationale: KDOQI 2020 and Fistula First initiative emphasize measurable targets; prolonged CVC use is a major infection risk.

Update 1.2 Buttonhole technique restriction

Buttonhole requires specific order + competency.

Buttonhole restricted to patients with limited cannulation sites (e.g., high AVF, deep access) AND nephrologist order. Mandatory use of antimicrobial ointment (mupirocin) post-dialysis if buttonhole used, per KDOQI 2020.

Rationale: Buttonhole has higher infection risk; mupirocin reduces S. aureus exit-site infections.

5 Procedure UPDATED

A. New Access Planning & Maturation UPDATED

Update 2.1 Maturation criteria & first cannulation

AVF maturation: 6 mm diameter, 6 mm depth, 600 mL/min flow, discernible margins.

Expanded criteria: diameter ≥6 mm, depth ≤6 mm, flow ≥600 mL/min, visible margins, and adequate thrill throughout. Vein mapping mandatory for all CKD Stage 4 patients. First cannulation: two-person (most experienced RN + preceptor), 17G needles for first 3 treatments, ultrasound guidance available.

Rationale: KDOQI 2020 emphasizes objective maturation criteria; two-person first cannulation reduces complications.

B. Routine Assessment – Every Treatment UPDATED

Update 2.2 Structured physical exam

Look, Listen, Feel with documentation.

Structured assessment with arm elevation test (AVF/AVG) – if the access collapses with elevation, consider stenosis. Pulse augmentation – check if pulse disappears with proximal occlusion. Document in HD Treatment Record.

Rationale: Physical exam maneuvers (elevation, augmentation) improve detection of stenosis before flow declines.

Look: Infection, aneurysm, swelling, hematoma, skin integrity, steal signs

Listen: Bruit – continuous, low-pitched at anastomosis + entire length

Feel: Thrill – continuous vibration. Pulse – downstream. Temperature.

Document: Thrill/bruit quality, changes from baseline, arm elevation test

DO NOT CANNULATE IF: Absent thrill/bruit, signs of infection, severe swelling, suspected stenosis. Notify MD immediately.

C. Cannulation – AVF/AVG Summary

Site Selection: Rope ladder technique. Sites ≥3cm from anastomosis, ≥2.5cm from other sites. Avoid aneurysms, center of gums, previous infiltration.

Preparation: 2% CHG + 70% alcohol, 30 sec scrub, air dry 2 min. No re-palpation after cleansing.

Needle: Gauge per order. Bevel up, 25-35° angle, direction per protocol.

Securing: Chevron taping. No occlusive dressing over sites during HD.

Limits: 2 attempts per person, 4 total per session. After 4, call MD. Consider CVC if urgent HD needed.

D. CVC Management – CDC Bundle Required UPDATED

Update 2.3 Dressing frequency & TPA protocol

Dressing changes: Q7d transparent, Q48h gauze, or if soiled. TPA: 2mg/2mL per lumen, dwell 30-60 min.

Dressing: transparent Q7d, gauze Q48h, or immediately if damp/loose/soiled. CHG-impregnated disc mandatory. TPA protocol expanded: if sluggish flow <200 mL/min or inability to aspirate, instill 2mg/2mL per lumen, dwell 30-60 min, aspirate and discard. May repeat x1 if needed.

Rationale: CHG discs reduce exit-site colonization; expanded TPA protocol improves catheter salvage.

E. Monthly Access Monitoring & Surveillance UPDATED

Update 2.4 Surveillance triggers & referral

Triggers: physical exam changes, venous pressures, Qa, recirculation, adequacy.

Expanded triggers: • Qa <500 mL/min (AVF) or <600 mL/min (AVG) OR ↓25% from baseline • Static venous pressure ratio >0.5 • Dynamic venous pressure >150 mmHg at Qb 200 (AVF) or >250 mmHg (AVG) • Recirculation >10% with URR <65% • Physical exam changes. Referral within 2 weeks for any trigger.

Rationale: KDOQI 2020 recommends multi-modality surveillance; static pressures improve stenosis detection.

Parameter	AVF Trigger	AVG Trigger	Action
Physical Exam	New aneurysm, absent thrill, prolonged bleeding >20min	Same + pulsatility	Vascular referral
Venous Pressures	≥150 mmHg at Qb 200	≥250 mmHg at Qb 200	Check trends x3
Access Flow Qa	<500 mL/min or ↓25%	<600 mL/min or ↓25%	Fistulogram
Recirculation	≥10% if URR <65%	≥10% if URR <65%	Evaluate needle position
Adequacy	Kt/V <1.2 despite Rx	Kt/V <1.2 despite Rx	Assess access

F. Complication Management UPDATED

Update 2.5 Steal syndrome & aneurysm monitoring

Steal: cold hand, pain, numbness → notify MD. Aneurysm: document size monthly.

Steal syndrome: assess with finger pulse oximetry (SpO₂ <90% in affected hand). If severe (ischemic rest pain, ulceration, gangrene) → stat vascular referral. Aneurysm: document size monthly; if >3x original diameter, skin breakdown, rapid growth, or pain → surgical referral within 2 weeks.

Rationale: Objective steal assessment (SpO₂) improves triage; timely aneurysm referral prevents rupture.

Infiltration: Stop pump, do not flush, remove needle, direct pressure 10+ min, ice/heat per protocol, document, incident report.

Infection (AVF/AVG): Redness, warmth, drainage → Hold cannulation, MD now, cultures, antibiotics.

Infection (CVC): Exit site score ≥2 or tunnel infection → MD now, may need removal.

Prolonged Bleeding >20 min: Assess heparin dose, needle sites, consider coagulation labs, refer if recurrent.

G. Patient Education – Documented Monthly UPDATED

Update 2.6 Home care & emergency education

AVF/AVG: no BP/IV/draws, no tight clothing, check thrill daily, wash pre-HD. CVC: keep dry, no swimming, report fever/drainage.

Add: • Emergency bleeding education: apply direct pressure, call ambulance, do not remove clot. • Monthly documentation of education on access preservation, signs of infection, and when to call the unit. • Access self-monitoring log for patients to record thrill check daily.

Rationale: Patient engagement and home monitoring improve access longevity and early complication detection.

7 Staff Competency UPDATED

Update 3.1 Access coordinator & advanced competencies

Initial: 10 supervised cannulations. Annual: written + observed. Access coordinator RN assigned.

Initial: 10 supervised successful cannulations on AVF and AVG separately. Annual: written exam + observed assessment/cannulation. Access Coordinator role expanded: RN assigned to track all accesses, referrals, outcomes, and lead monthly surveillance meetings. Advanced competencies: ultrasound-guided cannulation and fistulogram interpretation for senior staff.

Rationale: Expanded coordinator role improves surveillance compliance; advanced skills support complex access management.

8 Quality Monitoring – QAPI Indicators UPDATED

Update 4.1 New & refined quality metrics

Prevalence: AVF >68%, CVC <10%. Infection rates, infiltration <5%, thrombectomy rate, new AVF use within 90 days.

Add: • % of patients with monthly surveillance completed (Qa, pressures) – target 95% • CVC removal within 30 days of AVF/AVG maturation – target 90% • Buttonhole infection rate (if used) • Time from surveillance trigger to vascular referral – target <2 weeks.

Rationale: Process metrics (surveillance completion, referral timeliness) drive outcomes; buttonhole infection monitoring is critical.

9 References UPDATED

Update 5.1 Updated reference list

KDOQI Clinical Practice Guideline for Vascular Access: 2020 Update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1-S164.
Lok CE, et al. KDOQI Vascular Access Guideline Work Group. Am J Kidney Dis. 2020.
CDC. Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients. 2016.
National Kidney Foundation. Fistula First Catheter Last Initiative.
Ministry of Health – Hashemite Kingdom of Jordan. Standards for Hemodialysis Units, 2023 Edition.
MOH-Jordan Access Monitoring Guidelines, 2024.

⏺ Summary of key updates

Section	Update	Clinical rationale
4. Policy	Access hierarchy with targets (AVF >68%, CVC <10%); CVC removal within 30 days of maturation; Buttonhole with mupirocin	KDOQI 2020 targets; prolonged CVC use is infection risk; mupirocin reduces S. aureus infections
5. Procedure (A)	Expanded maturation criteria; two-person first cannulation; ultrasound guidance available	Objective criteria improve outcome; two-person reduces complications
5. Procedure (B)	Arm elevation test; pulse augmentation; structured physical exam	Maneuvers detect stenosis before flow decline
5. Procedure (D)	CHG disc mandatory; expanded TPA protocol (may repeat x1)	Reduces exit-site colonization; improves catheter salvage
5. Procedure (E)	Static venous pressure ratio; expanded triggers; referral within 2 weeks	Multi-modality surveillance; static pressure improves stenosis detection
5. Procedure (F)	Steal: SpO₂ assessment; stat referral for severe; aneurysm size + pain triggers	Objective steal assessment; timely aneurysm referral prevents rupture
5. Procedure (G)	Emergency bleeding education; self-monitoring log; monthly documentation	Patient engagement improves access longevity
7. Competency	Access coordinator leads surveillance; advanced competencies (US, fistulogram)	Improved surveillance compliance; complex access management
8. QAPI	Surveillance completion (95%), CVC removal within 30 days (90%), buttonhole infection rate, referral timeliness	Process metrics drive outcomes; buttonhole monitoring critical

Policy HD‑CL‑003 · Proposed updates June 26, 2026 All changes reviewed against KDOQI 2020, CDC 2016, and MOH‑Jordan 2023.

Vascular Access Management Assessment Cannulation And Complication Prevention · Version 2026-06-27 · Hemodialysis Unit

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Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.