Please help to settle a little bet I have with a co-worker. She insists that it is never appropriate to use a tourniquet when cannulating an AV graft. I think there are times when it is beneficial to do so. Thanks for your help.

When would you use a tourniquet on a PTFE graft? A few years back Marguerite Hartigan MSN, RN, CNN had an article in Advances in Renal Replacement Therapy that states a tourniquet can be used on a �mushy� graft. Now why is a graft �mushy�? Two reasons: One-site-it is from poor needle rotation and poor access flow within a graft. Look under DOQI Guideline # 10 Monitoring Dialysis AV Grafts for Stenosis 2 www.kidney.org. Grafts with an access flow (blood flow within the access from the artery) less than 600 ml/min have a higher risk of access thrombosis. The grafts can clot in 6 months or less. A graft access flow can be checked with the use of the Transonic Devices or Hct Line device. The true access flow on a �mushy� graft will show if the graft is �mushy� due to the low flow within the graft. A tourniquet might help �pump up� the graft- but the underlying issue will not be resolved. This short term fix can lead to graft clotting- the real issue of the poor flow needs to be determined and fixed. The graft may have a severe outflow stenosis causing the lower flow within the graft. The graft could even have an arterial inflow problem (rare in PTFE/ more common in a native AV fistula). A fistulagram of the graft will determine and can treat the cause of the stenosis leading to the low flow �mushy� graft.
If the �mushy� feeling is from one-site-it is then the best treatment is to avoid the �mushy� area and start good site rotation. The tourniquet might �Pump-up� the one-site-it is and lead to the worn out segment of PTFE to be re-cannulated.

Would you use a tourniquet for other reasons on a graft? If so what and what you want the tourniquet to do within the graft? Hope you didn't bet any money!

So I lose the bet...
UNLESS you agree that the following scenario is OK...
I feel a mushy graft. A tourniquet is required to dialate it enough to get it so I can stick it safely. Is it OK to go ahead and use the tourniquet to get the patient on dialysis if I call the doctor to report the problem ?

You know if I call the doctor without putting the patient on he'll say dialyze him and call the surgeon anyway. Then the patient will go to the ER where the surgeon will have his resident see the patient. He will deem this a non-emergency and send the patient home and schedule an outpatient appointment for the patient to come in and be evaluated. The appointment will be a week after the ER visit because they're so backed up. They determine there is a flow problem and a hemodynamically significant stenosis and the patient is scheduled for out patient surgery.
While all this is transpiring the patient needs to be dialyzed. We would need to apply a light tourniquet to cannulate the patient each time.

What do you think ?

Well Arliss,
The mushy graft takes time to form. If it is from one-site-itis, then the rest of the graft should not be mushy. Feel the entire graft outline for the �mushy� feel. If the graft is wearing out from too many stick- the graft feel will change over time before it feels �mushy�. With every cannulation a PTFE graft should me palpated over the entire cannulation segments of the graft (the mid loop area can also be palpated, but not used for cannulation). Site rotation needs to start from the virgin stick of any new PTFE with patient education and then on going. Get a sample PTFE graft from one of the vendors. Stick one side of the loop 12 times in the same general area to simulate one-site-it is. Then stick the other side of the loop 12 times with good site rotation. (12 sticks = 1 month of cannulations). Compare the difference. Hang up your graft model for the staff and patients to touch, feel the holes in the PTFE and realize why PTFE grafts need to needle sites rotated. The mushy graft did not get mushy in one day. Prevention is the best treatment and once a �mushy� area develops, just find an intact area of graft and cannulate there without the tourniquet.
If the graft is �mushy� due to poor flow- this also happens over time and subtle changes will be present. Monitor changes such as the blood flashback with cannulation. If a stenosis is developing the venous needle flashback can become more pronounced or stronger from the narrowing of the venous outflow tract. The arterial needle blood flashback will weaken as the bloodflow within the access slows down. The blood might appear a darker color as well. The flashback can often help predict a failing access.
The pre-pump arterial pressure will also change as the bloodflow within the access drops. The pre-pump arterial pressure is a negative number and it will become a more negative number as the access flow drops but the blood pump speed setting remains the ordered speed. As the stenosis is forming the increased venous pressure will also change and rise as the venous outflow is narrowed down. Once the access flow drops so low that an access will feel mushy- the venous pressure can also drop due to the very slow flow within the graft. You should find s/s before the flow would get so low that you would want to dialyze the patient with use a tourniquet to cannulate.
I would not send the patient back to the vascular surgeon. The patient should have a fistulagram done to identify the problem. A surgeon can look at the films and see if a surgical interventions is needed. The radiologist can perform the fistulagram and if a stenosis is found can treat it right then with angioplasty. No need to wait 1 week. A fistulagram can be done with ease any Monday-Friday (often even late PM with little warning). Need to work out the options with a local radiologist to do fistulagrams as a STAT procedure the day of an event or ASAP the next AM. Can be done as out patient procedure and the patient then returns for out patient hemodialysis right after.
You can also get great tools to do access flow measurement right at the chair side while on hemodialysis. The Transonic Device will give you access flow reading, recirculation % readings and true extracorporeal blood flow readings (not what the blood pump speed reads but the true flow within the blood tubing/dialyzer). The Crit-line can give you fluid status to help identify dry weight and prevent hypotension, spot Hct reading, recirculation % readings, access flow, and O2 saturation reading. You can use either of the devices to help monitor vascular access for possible failure. A color doppler can also check the access for access flow and any s/s of stenosis.
Be proactive not reactive! So no I would not use a tourniquet on a �mushy� graft any time. The access is the patient�s lifeline- it needs the loving care of great dialysis staff and the patient to prevent complications!!!!

P.S.
If you care enough to bet a co-worker then, you can bet on improving your patients care and outcomes. Keep asking the questions and hope you learn some new tricks to help with your daily care of hemo patinets!!! The risk of change is worth taking!
Deborah

I surrender !

Arliss
Don't feel bad- I hope you can now work towards preventing any "mushy" grafts in your unit and can teach others how to prevent "mushy" grafts. You can now work on identifying low flow grafts and get the grafts fixed before they clot!!! That would be worth more than any $ won on a bet!!!!
Deborah

I'm surprised that no mention is being made of a major cause of access failure. A lot of accesses fail because people wrap the arm too tightly after treatment. Blood pressure is usually lower, flow through the access is slower and it is a dangerous time for accesses. You are fighting human nature also. Patients are tired of being in that chair and anxious to go home. Staff are anxious to empty the chair for the next patient. Many patients suggest staff "wrap it tight" so it won't leak on their way to the scale or in the car on the way home. I believe this is a major cause of clotted accesses and encourage my patients to wait for the clot to form. Then and only then I place a 4 x3 over the sights and wrap tape 3/4 of the way around the arm. Unfortunately I've seen arms that look like overstuffed sausages on their way to the scale. It makes me cringe. Any other opinions?

Worthy,
You are right on!!! This certainly can lead to a clotted access. I like your description of the too tight tape jobs comomonly seen post dialysis in many units. The tape 3/4 only around the arm is a good practice. Keep up the good work with patient care and education. The hard part is getting staff to change old ways!!!
Deborah