How long are people usually waiting before cannualing a new AV? What type of exercise/treament is being used to develop these AV's.
What type of needles are being used at the start ie: size, etc. type
What pre education tools have been developed or are available other than the video's from the companies.

Susan,
Great question!! You should wait for 4 weeks before the virgin stick, but 3-4 months is much better. The goal of the virgin stick should be to cleanly cannulate the fistula with a 17 Ga. or 16 Ga. if big enough fistula needle with no infiltration or hematoma formation. You want the first stick to be a success and prevent any damage to the fistula. I found a 17 Ga. fistula needle placed into the fistula (often pointing towards the wrist anastomosis or in an upper arm fistula towards the elbow) worked better with less vessel spasm and better blood flow. The key is not to use lidocaine, be gentle and use a smaller needle and lower bloodflow rate. Give the vessel time to mature with use. Often the needle was used first as the arterial draw and once used for greater than 1-2 weeks, then increased used for both needles. Smaller 17 Ga. or 16 Ga. with lower bloodflow until the vessel can handle larger needles and a higher bloodflow rate. Bloodflow rate might need to be very low such as 200-250 ml/min. Pre pump arterial pressures are very useful to see how the fistula is tolerating the bloodflow rate. The venous pressure will be higher with the 17 Ga. needle as well as the pre pump arterial pressures will be more negative. It often works best to use the other access on the first and last treatment of the week and slowly use the fistula on the mid week treatment if the lower bloodflow is an issue for clearance. Mondays and Tuesdays are the worst days to try a virgin stick- everyone wants to get on and off. Wed and Thursday gives more time to work with the access without worries of the urgent need for treatment.
Would love to hear other suggestions!!!

The nephrologist and vascular access surgeon I work with are very progressive. They are both big advocates of early education for Pre-ESRD patients.
When it is determined that a patient will be going on chronic hemodialysis the nephrologist calls in one of the Training RN's and we start to talk about preservation of the vessels for potential access. We teach them how to use light weights to develop the blood vessels prior to their visit with the surgeon. This was actually the surgeon's idea.
We teach the patients, and their families if we can get them interested ( and we frequently do), what their options are in the way of vascular access for hemodialysis.
We also cover care of the new access and explain what the patient's role is in helping to maximize the life of that access.
We have 65% AVF in our unit. That's up from 50% last year. We have 10% catheters. That's down from 20% last year !
We don't attempt a first cannulation until it has been at least a month since the access was placed. Longer if it is a fistula. Lucky for us most of our fistulas are placed 3 months in advance on average. For patients that come to us with catheters as bridges, we start out with a 17 Ga. needle for the arterial and use the catheter for the return. We are very careful to monitor pre-pump arterial pressure. We generally move up after a couple of weeks to 16 Ga. needles if all is going well.
All the while the patients are encouraged to continue the light weight lifting. Some like to use a light tourniquet and squeeze a rubber ball or something similar.
We use the pre-pump arterial pressure as our guide to blood flow and needle selection. We never try to increase the blood flow to a point where the pre-pump pressure is more than - 250 mmHg.
We carefully document our physical assessment of the new access each treatment. We have monthly staff meetings to discuss our patients progess and one of the areas we focus on in these meetings is the access.
I believe we have a very good access management program at our clinic.
The fact that we get input from the nurses,technicians,dietician, social worker, nephrologist,surgeon, patient and their family I believe has been key to our success.

Carole,
What state or city is our unit in? Sounds like a great program. Would be wonderful to get your ESRD Network to look at your progam and try to copy it at other locations. Would also be a great article for on of the renal magazines!!! Keep up the great progress!
Deborah

Carol your program sounds wonderful - where are you located and how long did it take to get this program going. Does 1 person oversee this, how many patients do you have. You and your facility are to be commended. thanks for the information.