The needle insertion procedure for my company provides for the use of a tourniquet on an AV graft cannulation. The DOQI guideline that I've seen makes no reference to the use of a tourniquet with an AV graft. Is there any written authoritative guideline ? Some dialysis caregivers use a tourniquet. Others say they shouldn't be used in the cannulation of an AV graft. Does DOQI provide any specific guideline in this area? Thanks

Janice,
The DOQI Guidelines did not address cannulation (used the section from the ANNA Core Curriculum only). A graft that needs a tourniquet most likely has a low access flow (the blood flow within the graft) and is a s/s of a pending clot. The "mushy" graft is from the low flow or from a worn out graft segment (many holes in the PTFE). The use of the tourniquet will not help treat the low flow and if the graft is so worn- could lead to rupture of the remaining graft surface/pseudoaneurysm. In your nsg P+P what are the indications to use the tourniquet?

Thanks Janice. There isn't any indication. The procedure recommends application of a tourniquet to maintain distention of both grafts and fistulas for cannulation. I had a patient with a graft of about 7 months that was difficult to cannulate without the tourniquet. However, I didn't want to take any actions that could damage the graft. So, If there is information available to the contrary, I desired to bring it to the attention of my supervisor

Janice
A PTFE graft should be the same size (can be a tapered or straight PFTE graft), but the graft size should remain the same. The graft surface should remian intact and not with large areas of holes in the graft. Proper site rotation should prevent one-site-itis in the graft. The flow through the graft should be high enough to keep the graft from being flat or mushy. If the graft is palpated and it has an irregular outline or contour- than the graft has a worn out area from too many sticks in the same sites (one-site-itis) or the blood flow within the graft is low.

The need to dilate or distend the graft would be a sure sign of a low blood flow within the access.

Can you get an access flow measurement bedside in the unit with a Trasonics or Crit-Line monitor? Do you measure pre-pump arterial pressures?

The graft should be brought to the attention of the nursing supervisor and the MD. They may or may not be aware of low flow s/s in a graft and fistula.

A access flow measurement (Transonic, Crit-line, doppler) would identify the problem as flow related and a fistulagram or doppler would identiy the graft outline.

If the graft has a low flow the venous pressure will not be elevated due to the reduced flow and may appear as if the graft is OK. The pre-pump AP will become a more negative # as you try to increase the blood pump to a speed greater or equal to the flow within the access. Might need to be as high as 500ml/min, grafts will clot at flows less than 600 ml/min.

The routine use of a tourniquet is not needed for grafts and should not be used. It could help to prevent the detection of graft problems. Talk with your supervisor and MD and see what they think. They can always post questions on this site as well.

By you asking the question shows a great commitment to high quality patient care. They should be proud of you and commend you on your willingness to learn new concepts. Keep asking the questions!!!

[This message has been edited by Deborah Brouwer (edited 07-27-2000).]