Question: Does anyone have any information on the use of a tourniquet to cannulate a PTFE graft? or on any synthetic graft?

I've been using tourniquets on AV grafts that are difficult to stick for several years... at the reccomandation of a MD whom I worked with when I wsa very new to dialysis nursing. Recently, I recieved some negative feedback from another MD (we all know how friendly and polite our doctors can be) about using a tourniquet to cannulate a patient's graft.

So... I'm wondering if there is any official guidline for the use of a tourniquet on grafts. I've read the NKF's DOQI reccomended procedure for cannulation.. and they do not mention the use of a tourniquet for grafts OR fistulas. My company's policy doesn't comment on the isue one way or the other. Anyone out there have a company policy that deals with this issue? Or ANY other literature on the subject?

Thanks,
Bryan
bwetter1@tampabay.rr.com

Bryan,


The post under new fistula cannulation has information about using a tourniquet with a fistula.

For A-V grafts, the only reference for using a tourniquet is:

Hartigan MF: Vascular access and nephrology nursing practice: Existing views and rationales for change. Adv Ren Replace Ther 1:1555-162, 1994

In my option a A-G graft that needs a tourniquet in place to cannulate has a low access blood flow within the graft. The use of the tourniquet helps to pop up or dilate the �mushy� graft. The problem is not the �mushy� graft, but the low access blood flow. The tourniquet can mask the underlying cause of the �mushy� graft. A graft that requires a tourniquet for cannulation needs an immediate evaluation for low access blood flow. Access blood flow can be determined with the use of the Transonic, Crit-Line or Doppler studies. A graft with low flow as defined by the DOQI Guideline 10, is a graft with access blood flow less than 600 ml/minute. The less than 600 ml/min flow places the graft at a higher risk of thrombosis.

Please contact Medisystems for a copy of the Access Management videotapes
(800)-369-MEDI. web site is www.medisystems.com
1. The Native AV Fistula: the Keys to Optimal Vascular Access
2. The AV Graft: Maintaining a Healthy Vascular Access

Cannulation techniques are all based on theory at the present time.

Thanks for the great question. Hope this helps answer your question.

Deborah


[Note: This message has been edited by Deborah Brouwer]

Thanks for your reply It was very helpfull.

Allow me to ask yet another question.

What I'm looking for is this, some reference that says application of a tourniquet is an appropriate intervention when cannulating a difficult AV graft. i.e. one with no palpable thrill, or one that feels small or partially collapsed. Or, on the flip side... a reference that says not to use a tourniquet on an AV graft.

Also, are there any potential adverse effects to using a tourniquet on an AV graft? i.e. thrombosis or damaging the anastomosis? I've asked these questions of several of my co- workers, with a very wide range of answers in response.

Any help or info would be appreciated.

Thanks,
Bryan
bwetter1@tampabay.rr.com

Bryan,

All current cannulation techniques are based on theory, not clinical studies. The references are all theory based.
The Hartigan reference does state to use a tourniquet on a �mushy� graft. The reference also gives the rationale as lower access blood flow secondary to the peripheral vascular disease and small arterial inflow. The reference also suggests the tourniquet may prevent trauma to graft.

My concern with the tourniquet is the issue of masking the low flow. If a graft has a very week thrill, the access flow is low and needs evaluation. Also a �mushy� graft can be caused by �one-site-it is� and not low flow. �Mushy� needs to be clearly defined. If the graft is all over �mushy� and flat with a weak bruit/thrill, then it might have a low access blood flow. If the graft is �mushy� in the most common cannulation areas, then the problem is lack of good needle site rotation leading to �one-site-it is�. Graft cannulation reference is Brouwer D. Cannulation Camp: Basic Needle Cannulation Training for Dialysis Staff. Dialysis & Transplantation (24) 11, Nov 1995 pp. 606-612

We need clinical studies to answer the very important questions about the best cannulation techniques. Until science shows us the correct way, we must rely on theory.

Deborah