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The Care and Keeping of Vascular Access for Home Hemodialysis Patients

Running Head: Vascular Access in Home Hemodialysis

Authors and Affiliations:

Rose Faratro, RN, BHScN, CNeph(C)1
Janine Jeffries, RN2
Gihad E Nesrallah, MD, FRCPC, FACP3
Jennifer M MacRae, MSc , MD, FRCPC4

1University Health Network, Toronto, Ontario, Canada;2Princess Alexandria Hospital, Brisbane, Australia; 3Humber River Regional Hospital, Toronto, Ontario, Canada;4University of Calgary, Calgary, Alberta, Canada

Corresponding Author Contact Information
Jennifer M MacRae MSc MD FRCPC
Cummings School of Medicine
University of Calgary
1403 29th Street NW
Calgary, AB T2N 2T9
Phone: +1 403 944-8168

Email: Jennifer.macrae@albertahealthservices.ca

Conflicts of Interest:

RF, GN, JJ and JM have no conflicts to declare.


See “Global Forum on Hemodialysis in the Home: Sponsorship and Disclosure Statements”


home hemodialysis, vascular access, arteriovenous fistula, cannulation, buttonhole cannulation, rope ladder cannulation


Arteriovenous Fistula
Buttonhole Cannulation Technique
Complications of Buttonhole Cannulation
Increased Risk of Infection with Buttonhole Cannulation
Tools to Determine the Best Type of Needling
Fistula Cannulation Methods
Troubleshooting Arteriovenous Fistula Complications
Arteriovenous Graft
Central Venous Catheter
Troubleshooting Catheter Complications
Key Performance and Quality Indicators


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Creating and maintaining a healthy vascular access is a critical factor in successful home hemodialysis (HD). This module aims to serve as a “how-to manual” regarding vascular access issues for both patients and healthcare providers in a home HD program. This module outlines cannulation options for patients with arteriovenous access and describes troubleshooting techniques for potential complications; strategies are suggested to help patients overcome fear of cannulation and address problems associated with difficult cannulation. Technical aspects of central venous catheter care, as well as a guide to troubleshooting catheter complications, are covered in detail. Monitoring for access-related complications of stenosis, infection, and thrombosis is a key part of every home HD program. Key performance and quality indicators are important mechanisms to ensure patient safety in home HD and should be used during routine clinic visits.

Arteriovenous Fistula

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Arteriovenous Fistula Cannulation Options

Cannulation of the arteriovenous fistula (AVF), even when done properly, causes pain and local trauma; repeated cannulation can weaken blood vessel walls and promote wall dilation and the formation of aneurysms.1,2 Unsuccessful cannulation can result in needle infiltration (swelling that happens when the needle goes through the fistula wall), which in turn causes localized bruising and increases the risk of thrombosis and loss of AVF patency.3

Two methods of needling are commonly used: rotating sites/rope ladder (RL) technique, and buttonhole (BH) technique. The standard is RL, wherein the needling site is alternated along the length of the AVF, resulting in minimal scar tissue formation. Many patients are trained on this method of cannulation when beginning home dialysis. While discouraged, some patients prefer particular sites (ie, use the “area wall technique”), which increases the potential for damage to the AVF wall and dilation of the fistula, and can result in the development of an aneurysm.4-6

The BH technique, also known as constant site needling, is a cannulation method that uses the same location, angle, and depth repeatedly.1,2 Sharp needles are used to form a tract of scar tissue for entry into the fistula over time. Once this tract is formed, the patient can begin cannulating using a blunt needle, which is theoretically less traumatizing to the vascular structure and should improve survival of the access.1

To date, there are no high-quality clinical trials comparing AVF outcomes with RL vs BH cannulation in home HD patients or other self-needler patients (Table 1). The majority of the evidence supporting the use of the BH technique was generated through observational studies, and the generalizability of the existing observational and clinical trial data to the self-needling patient is unknown.

Useful Resources
La Société Française de l’Abord Vasculaire. History of Buttonhole Technique:

End Stage Renal Disease Network. Cannulation of the AV Fistula:

Buttonhole Cannulation Technique

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In each unit, specialized, highly trained clinic staff are responsible for teaching BH tract creation. Ideally, there should only be 1 cannulator for the BH, and it is best if that cannulator is the patient himself; however, there are cases where a dedicated helper can be taught to cannulate. It is very important that the angle, position of the arm, and tourniquet placement are kept constant with each cannulation in order to create and maintain the BH tract. Previous teachings have suggested that the angle of entry should be 45 degrees for all BH cannulations, but in fact, the angle of entry depends on the depth and the anatomy of the fistula, and, thus, varies with each patient. To provide consistency for the angle of needle insertion, the touch cannulation technique can be taught. This technique refers to the placement of the thumb and forefingers on the needle tubing (and not the wings) while the other fingers rest upon the arm to provide stabilization (for more information and cannulation images, see End Stage Renal Disease Network, Cannulation of the AV Fistula at http://esrdncc.org/ffcl/change-concepts/change-concept-8/cannulation-of-the-av-fistula/).

Many clinics recommend that 2 separate BH sites (ie, 2 arterial and 2 venous) be created, each 6 to 8 cm apart. Ideally, patients should alternate between these sites and if there is ongoing difficulty with accessing a site or if it becomes infected (see section Increased Risk of Infection with Buttonhole Cannulation), that site should be abandoned.

BH tract creation requires repeated cannulation with a sharp fistula needle, an intravenous (IV) needle, or placement of a polycarbonate peg (eg, BioHole™ Plug, Nipro Corporation, Belgium). With each of these methods (except for the peg, which has no scab formation), the scab on the BH tract is removed before cannulation to allow the access site to be viewed and permit accurate insertion of the needles. The needles are inserted using the exact location, angle, and depth for each HD treatment. Canadian guidelines suggest that topical antimicrobial prophylaxis be applied to the BH site after the dialysis treatment is completed.15

The most common way to create a BH tract is with any type of sharp standard HD needle. The BH is initially created after approximately 8 to 12 cannulations using this approach. Once the BH tract is developed, the needles are switched to a dull/ blunt BH needle (eg, Medisystems) or a dull/blunt IV needle with a plastic cannula (eg, Nipro BioHoleTM Cath) to cannulate the BH sites.

Intravenous needles with plastic cannulas (eg, the SupercathTM Clampcath or angiocatheter) have also been used to create BH tracts with repeated needling. As described above, these needles are also inserted into the exact spot, using the same angle and depth for each HD treatment; the scab on the BH is removed before cannulation. Once the BH tract is developed, the blunt version of these needles can be used to cannulate the BH sites. These types of catheters have a large enough cannula to sustain dialysis blood flow, and the plastic (instead of steel) cannula limits the potential for needle infiltration.

Of note, there are descriptions in the literature using these IV needles with plastic cannulas to create a BH by leaving the catheter indwelling for periods of time.16 Readers should be warned that there are possible complications with these indwelling catheters, namely the chance of infection, needle dislodgement, and cannula breakage with migration into a vessel.17 The authors have personally treated catheter breakage in patients who have used this technique and we do not recommend this approach.18

Polycarbonate pegs are emerging as preferred tools with which to create BHs. The peg is a small, sterile, thumbtack-shaped plug used to maintain the needle tract between cannulations. Scar tissue forms around the peg, which facilitates the development of the BH tract. The use of a polycarbonate peg may lead to improved tract creation, which may in turn improve AVF survival. A randomized trial by Vaux et al 8 used polycarbonate pegs to create BHs, and they found improved AVF survival with BH cannulation at 1 year, whereas with conventional BH tract formation, there was no difference in AVF survival in a comparison with RL needling.19 (See Buttonhole Tract Formation Using Polycarbonate Pegs in the Appendix) Note that some, but not all, BH protocols include antibiotic prophylaxis.20,21

The BH technique is not recommended for all patients and is contraindicated in patients with arteriovenous grafts (AVGs). In North America and Australasia, the BH technique is considered a relative contraindication for newly created AVFs because the fistula is undergoing dynamic changes that influence the BH tracts; however, this practice is not consistent globally. In Europe, BH cannulation is performed in patients with newly created fistulae.

Indications for and against BH cannulation are summarized in Table 2, and a checklist for assisting clinicians in choosing the best cannulation method for patients can be found in Criteria for Determining Type of Self-Cannulation in the Appendix. Choosing a cannulation method is discussed further in the section Tools to Determine the Best Type of Needling. Patients with limited vision should use prescription lenses or a magnifying glass during the self-cannulation evaluation.

Useful Resources
Big D and Me. Dialysis Buttons for your Buttonholes:

Home Dialysis Central. The Art of Teaching Buttonhole Self-Cannulation:

Complications of Buttonhole Cannulation

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Over time BH sites can develop a widening and an indentation at the entry to the skin. This is commonly known as “hubbing”. Hubbing occurs when the hub of the needle is buried into the skin, which can result in incomplete scab removal, patient’s inability to clean the puncture site, and breakdown of the lining of the tunnel tract.22 Hubbing can be prevented by leaving space between the hub of the needle and the puncture site.

Trampoline Effect

The trampoline effect describes the motion of a blunt needle meeting resistance and bouncing back toward the cannulator. This occurs because of a thickening of the tunnel tract or poor tract development. When this occurs, the patient’s needling technique should be reassessed.

Increased Risk of Infection with Buttonhole Cannulation

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Several clinical studies have demonstrated an increased risk of infection with the use of BH cannulation.5-7, 21-26 The incidence of localized infections is increased with BH and other infectious complications have been reported. These include septic arthritis, bacterial endocarditis, and bacteremia; however, these conditions may not appear until long after the BH technique is initiated.5,6, 24-26 While incidence of infection varies between studies (and by patient population and locality), 1 retrospective study reported a rate of bacteremia of 0.073 per 1000 AVF days for BH patients, compared with no bacteremia for RL patients.26 One systematic review of observational and randomized studies reported an increased risk of AVF-related infections using BH cannulation, with relative risk ranging from 3.15 to 3.34 comparing before and after changes and with RL cannulation, respectively.27

Patients should be informed of the increased risk of infection and receive specialized training and frequent evaluations of their cannulation techniques.15 Strict adherence to aseptic technique in performing cannulations is essential; additional measures of infection prevention are also recommended for BH patients (Table 3).15,23, 28,29 Each clinic should track and regularly review infection rates (see section Key Performance and Quality Indicators).

Management of BH Infections

The optimal duration and choice of antibiotic therapy to treat BH-related infections has not been directly studied. The following suggestions are based on the authors’ opinions. Empiric treatment should begin with a first-generation cephalosporin (eg, cefazolin) or vancomycin, depending on local methicillin-resistant S aureus (MRSA) colonization rates. Subsequent choice of antimicrobials should be based on culture and susceptibility results.

Tools to Determine the Best Type of Needling

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For patients with AVF, the RL method of cannulation is the preferred type of needling.15 In general, RL cannulation is used with an AVF that is of adequate length and superficial depth. In addition, the RL method is favored among patients who have poorer vision or those who have a slight tremor. However, in patients who have an AVF that is of short length, consists of tortuous anatomy, or involves aneurysmal sections, BH cannulation should be considered (see Table 2). Patients with a needle phobia can often overcome this phobia with the BH cannulation technique (see Fear of Needles in the Appendix). Due to the increased risk of infections with BH, this technique is not recommended for patients with a history of AVF infections, mechanical heart valves, or other prostheses.

A downloadable tool to assist clinicians in choosing the most appropriate type of self-cannulation can be found in Criteria for Determining Type of Self-Cannulation in the Appendix.

Fistula Cannulation Methods

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Indications for Use of Standard Sharp Fistula Needles

Standard sharp fistula needles are used if the patient is unable to cannulate using the IV needle with cannula or with the dull/blunt needle at a BH tract. If the sharp fistula needle is used, then the patient is encouraged to cannulate at a new site rather than using the established BH tract. The use of sharp fistula needles for nocturnal dialysis is not preferred due to the potential for needle infiltration during the treatment. However, if sharp fistula needles are used for nocturnal dialysis, it is imperative to ensure that these needles are secured well. See Taping Methods for Hemodialysis Needle and Taping Method of Intravenous Needle with Cannula protocols in the Appendix. For more information on nocturnal dialysis, see Prescriptions for Home Hemodialysis.

Indications for Use of IV Needle with Cannula

(Examples: Supercath Clampcath Needles, Nipro Biohole Cath)

For nocturnal dialysis, the flexible cannula is used for comfort and to prevent needle infiltration during treatment. The use of this needle system should be considered in:

Protocols on use of IV needle with cannula can be found at:

Indications for Use of Dull/Blunt Needle

For nocturnal dialysis the dull/blunt needle is used to prevent needle infiltration during treatment. When used with the BH technique, once the BH tract is created, a dull/ blunt needle can be inserted into that tract for the dialysis treatment. Protocols on use of dull/blunt needles can be found at:

Additional Cannulation Reference Tools
End Stage Renal Disease Network. Cannulation of the AV Fistula:

BC Renal. Vascular Access Guideline, Rope Ladder Cannulation of AV Fistulas and Grafts:

Home Dialysis Central. The Art of Teaching Buttonhole Self-Cannulation. Step-by-step PDF booklet with color photos:

Troubleshooting Arteriovenous Fistula Complications

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Centers should conduct technique review of self-needling patients every 3 months, with the patient being examined while cannulating in the clinic or during a home visit (see Arteriovenous Fistula/Graft Audit Tool in the Appendix). The major focus here is on prevention of infections.

Pain with Needling: Strategies

For patients who experience painful needling, a warm compress should be applied to the access site 5 to 10 minutes before needling. A topical anesthetic (preferred to a subcutaneous injection of lidocaine) should be used to numb the skin surface. Topical lidocaine preparations can be applied to the skin at the desired cannulation sites in a thick layer and then covered with an occlusive dressing or plastic wrap for 60 to 120 minutes prior to cannulation. Of note, the anesthetic needs to be thoroughly washed off the skin prior to cannulation. It is best to avoid injection of lidocaine into BH sites to minimize the chance for vessel and BH tract movement and potential for vasoconstriction of the blood vessel.

Cannulation Dependency Issues

Some BH patients may become fearful of cannulating using sharp needles at sites other than at the BH site. As a result, these patients can become dependent on the home HD clinic to troubleshoot access issues and reestablish the BH site.

Fear of Needles

Fear of needling can be a barrier to the uptake of home dialysis.31 Needle fear should not be a contraindication to teaching self-cannulation. In fact, this fear can be overcome if a stepwise approach is followed in which the patient slowly increases his or her comfort level with needles. Patients should start off simply watching the insertion of another patient’s needles, followed by watching the insertion of his or her own needles. Becoming familiar with simply holding the needles and holding needle sites after needle removal is also an important step. For more information, please see: http://www.homedialysis.org/life-at-home/articles/dialysis-needles-self-cannulation-and-the-buttonhole-technique or Fear of Needles in the Appendix.

Strategies for Addressing Difficult Cannulation

Patients who experience difficulty with cannulation should be scheduled to return to the home HD unit as soon as possible for a review of their cannulation technique and an access assessment for a possible complication of stenosis or thrombosis (Table 4). Thus, in addition to a physical examination (see Physical Examination of the Fistula), an access flow assessment should be made with a subsequent plan for intervention, if needed.

Regardless of the type of cannulation, patients should be instructed to avoid flipping needles. Flipping a sharp needle can actually damage the vessel, while flipping a blunt needle may be indicative of an underlying access problem.

Some home HD programs will use heparin locks or flushes to ensure patency of the access when patients experience temporary cannulation difficulties (eg, if needling is difficult due to onset of stenosis) or in those who need extra guidance for needling. Locking involves instilling a diluted heparin solution into the cannulas (needles and tubing) of the arteriovenous access and allowing it to dwell for a specified period of time (ie, “locking” the heparin in the lumens); flushing involves passing diluted heparin through the cannula before initiating dialysis. Some programs may substitute citrate 4% for the heparin. Before using this approach, patients should be informed of the potential risk of needle dislodgement and possible sequelae, such as bleeding and infection. More information can be found in the Heparin Flushing of Cannulas protocol in the Appendix.

Appropriate Blood Pump Speeds

The ideal blood pump speed for HD is unknown. However, there are potential deleterious effects of high blood pump speeds on fistula integrity. Needle turbulence is the intense flow that is created by a needle in an arteriovenous access, and has been shown to cause endothelial dysfunction with decreased nitrous oxide formation and loss of endothelial integrity.32,33 The effect of higher pump speeds has not been proven, but injury to the endothelial wall from altered flow mechanics of high pump speeds is likely to occur.34 Expert opinion recommends that lower pump speeds should be used to promote vessel integrity and maintain fistula longevity. More information on pump speeds used for different HD modalities can be found in the Prescriptions for Home Hemodialysis module. Regardless of the blood pump speeds utilized, most programs aim to maintain the arterial and venous pressures below -250 and 250 mm Hg, respectively; however, these pressures are not strongly evidence-based. A recent observational study of patients on in-center HD reported an increased risk of access failure with venous pressures outside the range of 100 to 150 mm Hg.35

Physical Examination of the Fistula

The access arm must be examined regularly by the patient. Routine evaluation of the arm using a “look, listen, and feel” approach may help detect access complications and subsequent intervention before the access is lost entirely. For an excellent description of the access physical examination, see Sousa et al.36

Monitoring for Complications of Stenosis and Thrombosis

Studies have not been performed to assess the value of access surveillance among home HD patients, but most programs recommend pursuing access flow monitoring when the patient returns for quarterly or biannual clinic visits. In addition, regular physical examination of the access by staff is suggested at these clinic visits.

Home HD patients should be taught how to perform a basic access arm examination regularly using the “look, listen, and feel” approach. Patients should be instructed to assess their access using the Arm Raise Technique. They will pump their hand to make a fist, raise their arm straight in the air, and, while standing in front of a mirror, note if the AVF collapses (normal state) or if the AVF does not collapse, which indicates an outflow obstruction.

It is recommended that patients perform trend analysis by recording the venous and arterial pressures at onset of each run at a blood pump speed of 200 mL/min, and reviewing the changes/trends in these numbers. During dialysis, the maximum arterial pressure should not exceed -250 mm Hg and the maximum venous pressure should not exceed 250 mm Hg. When these pressures are exceeded, the needle should be repositioned and/or the blood pump speed should be decreased. Patients should report to their clinician any changes noted in their routine access arm examination, trend of pressures, or cannulation, and the time of onset of cannulation difficulty.

Recent onset of increased difficulty of needling or prolonged bleeding from the access site after dialysis may be signs of an underlying stenosis and should be investigated. It is important to remember that as the AVF matures, BH tracts may change and new sites may be required, which may lead to difficulties in needling. In addition, large fluctuations in body weight or size can alter the BH tracts. Patients and staff should be aware that any new onset of cannulation difficulty can also be due to a hemodynamically significant stenosis or impending thrombosis of the access.

Access flow monitoring is suggested at a frequency of every 4 to 6 months, with the same flow thresholds for intervention as are used with in-center conventional HD patients. The same guidelines have been extrapolated for home HD patients.

Readers should note that there is considerable variability in the frequency of screening AVF/AVG. Some centers assess access flow every 6 months, while others screen more frequently (every 3 months) in cases of AVF with access issues. Other centers only investigate when cannulation difficulties are reported. Screening options include, but are not limited to, formal ultrasound study, Doppler assessment, clinical screening of needling complications, and review of technique quarterly (see Arteriovenous Fistula/Graft Audit Tool in the Appendix). Additional information can be found at:


Often, the first sign of impending thrombosis is what is mistaken for cellulitis, with signs of erythema over the AVF and tenderness to palpation. This is a medical emergency and the patient should be brought in for immediate physical and ultrasound examination of the AVF, with arrangements for radiology or surgical thrombolysis made as required. Every effort should be made to salvage the access and avoid catheter placement.

Fistula Hemorrhage

Hemorrhage from fistula has been reported in the in-center HD population,38,39 but the incidence of this occurring among home patients is unknown. All patients should be instructed to apply pressure to their site in the event of bleeding and to call for emergency assistance (eg, 911, 991, 999, 112, or 000 as appropriate). For additional information on fistula hemorrhage and patient safety during home HD, please see the module titled Patient Safety in Home Hemodialysis: Quality Assurance and Serious Adverse Events in the Home Setting.

Specific risks for home HD patients include needle dislodgement, or improper threading of the dialyzer, which may lead to significant hemorrhage. Water or enuresis alarms strategically placed under the dialysis machine and dialyzer, as well as under the access arm, help prevent these serious adverse events. Some popular alarms include the following:

An aneurysmal fistula that is rapidly enlarging in size could indicate possible rupture and hemorrhage.40 Thus, aneurismal fistula should be routinely monitored and the diameter of the aneurysms should be noted at each clinical visit. Fistula with necrotic skin as a result of infection can also lead to increased risk of rupture, especially in the case of BH cannulation.

The use of a single needle to minimize bleeding risk has been used in some programs; however, this results in a reduction in clearance and an increase in noise from the double pump system. The routine use of single needle in home HD has fallen out of favor, but it can be a useful technique to provide rest (and avoid a catheter placement) after AVF complications. Programs should have a standardized management plan for patients and caregivers to follow to manage hemorrhage, if it occurs in the home. For more detailed information, please see Home Dialysis Central, The Art of Making Your Fistula or Graft Last (http://www.homedialysis.org/life-at-home/articles/art-of-making-your-fistula-or-graft-last) or the Patient safety in Home Hemodialysis: Quality Assurance and Serious Adverse Events in the Home Setting module.

Fistula Infection

AVF infections can manifest as cellulitis, BH exit site infection, or bacteremia. Cellulitis is infrequent in mature AVF without skin lesions, but signs of redness and swelling should be evaluated to rule out thrombophlebitis. With a BH exit site infection, pus and erythema may be present at the needling site. It is important to obtain a swab for culture and sensitivity and 2 sets of blood culture specimens to rule out bacteremia (particularly S aureus bacteremia), which is very common with BH sites. See Increased Risk of Infection with Buttonhole Cannulation for details.

Two sets of blood culture specimens should be drawn from any HD patient with an unexplained fever. Some units initiate empiric therapy against both Gram-positive and Gram-negative bacteria, depending on the usual types of infection in that unit. The planned duration of therapy for bacteremia is 4 to 6 weeks, depending on the organism.

Arteriovenous Graft

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AVGs do not have the option of BH needling; only the RL and site rotation technique is recommended. Needle options include standard AVF/AVG needles (sharp) or the needle with cannula (angiocatheter) in which a blunt cannula remains in the AVG for dialysis. With the exception of AVG infection (see below), all other sections of the AVF apply to AVG.

AVG Infection

Central Venous Catheter

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Technical Aspects of Catheter Care

Routine placement of catheters in the subclavian vein (central venous catheters [CVCs]) is not recommended because they create a higher risk for central vein stenosis. In general, the internal jugular site is preferred.41 There are many different catheters available; however, there is no evidence to guide selection of 1 device over another.

Catheter Care Protocols

There are many catheter care protocols available (see Central Venous Catheter Audit Tool in the Appendix). In general, donning clean gloves and mask are a requirement when accessing the catheter.39


After dialysis, catheters are most commonly locked with citrate 4% and heparin at a concentration of 1000 or 5000 U/mL; however the following should be considered in selecting a lock solution:


Closed-Connector Devices

A closed-connector device is a device that is designed to decrease the risk of unintentional disconnection examples of which include:

As published in the most recent Canadian Society of Nephrology Intensive HD guidelines, a closed-connector device is recommended for patients receiving intensive (home) HD.15 These closed-connector devices are ideal for home HD patients with a CVC who perform HD without any assistance, as there is less risk for air embolism or chance of inadvertent bleeding. Depending on the device, these closed connectors can be changed under sterile conditions either weekly by the patient at home or monthly by the nurse at the home HD unit. To decrease concerns of air embolism at the time of exchange of a closed-connector device, the patient can be taught to double clamp (ie, use the catheter clamp and another separate clamp on the catheter tubing).

Exit Site Prophylaxis

The use of exit site prophylaxis (polysporin, mupirocin/bactroban, medi-honey, povidone-iodone, etc) is very center dependent and not used at every center.41

Showering Protocols

Attached is an example of a protocol for patients from an established home HD program (see the Showering Protocol in the Appendix). Remember that the shower and shower head are potential sources of bacteria; therefore, regular cleaning of both is recommended.

Troubleshooting Catheter Complications

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Catheters have a higher rate of infectious complications than arteriovenous accesses, a risk which appears to vary over time according to the length of time the access is in place.47 Catheter-related infections can be either local (as an exit site or tunnel infection) or systemic (bacteremia).

Exit site infections are defined according to a purulent discharge at the exit site with 2 of the following features:

If left untreated, exit site infections can lead to catheter-related bacteremia. An exit site infection is generally treated with a 2-week regimen of either topical or oral antibiotics.

A tunnel infection should be suspected in a patient who presents with pain or tenderness at the catheter exit site; the tunnel site should be palpated with the intention of expressing a discharge. A tunnel infection is defined as a purulent discharge or aspirate from a tunnel site not contiguous with the exit site and includes 2 of the following features:

Tunnel infections should be treated with a 3-week course of IV antibiotics.

Most HD units use the definition of a probable catheter-related bacteremia, which is 2 or more blood culture specimens that are positive for infection with no evidence for a source other than the catheter. When a patient first presents with a fever and suspected catheter-related bacteremia, start empiric antibiotics that cover both gram-positive and gram-negative organisms. The choice and duration of antibiotics, as well as the decision to remove the catheter, depend on the bacterial organism isolated.41 An example of a center protocol is included (see Central Venous Catheter Antibiotic Treatment Protocol in the Appendix) and detailed treatment guidelines can be found on the CARI website at: http://www.cari.org.au/DIALYSIS_va_published/Treatment%20of%20dialysis%20catheter%20infection.pdf.

Catheter Dysfunction

Catheter dysfunction is a common problem for catheter-dependent patients and results in decreased dialysis efficiency. Definitions of catheter dysfunction vary, but in general they relate to the inability to achieve a certain blood pump speed (from 200 to 300 mL/min) within the venous and arterial pressure limits of 250 and -250 mmHg, respectively, while dialyzing. Many HD units have developed treatment algorithms for decreased flow, which include checking patient positioning and flushing the lumens with normal saline prior to administering TPA. Home HD units that have adopted these protocols and will either instruct the patient to administer TPA at home or to come back to the unit to have staff administer the thrombolytic. Sample protocols can be found here:

Catheter Malfunctions

At times, an HD catheter may develop a crack in the line; generally, these lines will need to be replaced. If the crack develops distal to the “Y” portion, some lines can be repaired. Sample guidelines for determining when a catheter line can be repaired can be found at:


There have been reports of air embolism occurring in home HD patients using catheters.49 Prevention of air embolism by using a closed-connector device, such as those mentioned previously, is recommended.15 In a survey of Canadian Home HD programs, near misses have been reported in some patients who use connector devices when the device is not applied firmly.


Although the closed-connector devices may prevent air emboli, there have been cases of hemorrhage that have occurred in patients because the devices have been used improperly or the membranes in these devices have failed.15 Wetness detectors can be applied to the catheter for overnight dialysis (see Patient Safety in Home Hemodialysis: Quality Assurance and Serious Adverse Events in the Home Setting module).

Key Performance and Quality Indicators

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Key indicators are important operating mechanisms to ensure patient safety in home HD (see Patient Safety in Home Hemodialysis: Quality Assurance and Serious Adverse Events in the Home Setting module). Ensure these key indicators are used and followed during routine clinic visits for home HD patients to minimize complications of infection and to determine access failure:

Performance Measures

Quality Indicators


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Vascular access is associated with the development of potential complications that can lead to significant morbidity. Thus, the care and keeping of vascular access is a skill that is of utmost importance for home dialysis patients. Teaching patients their cannulation options as well as encouraging them to be vigilant for possible access complications should be a large part of every home dialysis program. Furthermore, routine access screening and review of quality indicators should be instituted on a regular basis to minimize access failure.

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  12. Kim MK, Kim HS. Clinical effects of buttonhole cannulation method on hemodialysis patients. Hemodial Int. 2013; 17:294–299.
  13. Sukthinthai N, Sittipraneet A, Tummanittayangkoon B, Vasuvattakul S, Chanchairujira T. Buttonhole technique better than area puncture technique on hemostasis and pain associated with needle cannulation. J Med Assoc Thai. 2012; 95 Suppl 2:S208–212.
  14. Chow J, Rayment G, San Miguel S, Gilbert M. A randomised controlled trial of buttonhole cannulation for the prevention of fistula access complications. J Ren Care. 2011; 37:85–93.
  15. Nesrallah GE, Mustafa RA, MacRae J, et al. Canadian Society of Nephrology guidelines for the management of patients with ESRD treated with intensive hemodialysis. Am J Kidney Dis. 2013; 62:187–198.
  16. Marticorena RM, Hunter J, Cook R, et al. A simple method to create buttonhole cannulation tracks in a busy hemodialysis unit. Hemodial Int. 2009; 13:316–321.
  17. Donnelly SM, Marticorena RM, Hunter J, Goldstein MB. Supercath Safety Clampcath buttonhole creation: complication of catheter breakage. Hemodial Int. 2013; 17:450–454.
  18. MacRae JM, Tai DJ, Daniw M, Lee J. A simple method to create buttonhole cannulation tracks in a busy hemodialysis unit. Hemodial Int. 2010; 14:94–95.
  19. MacRae JM, Ahmed SB, Hemmelgarn BR, Alberta Kidney Disease Network. Arteriovenous fistula survival and needling technique: long-term results from a randomized buttonhole trial. Am J Kidney Dis. 2014; 63:636–642.
  20. Marticorena RM, Hunter J, Macleod S, et al. Use of the BioHoleTM device for the creation of tunnel tracks for buttonhole cannulation of fistula for hemodialysis. Hemodial Int. 2011; 15:243–249.
  21. Toma S, Shinzato T, Fukui H, et al. A timesaving method to create a fixed puncture route for the buttonhole technique. Nephrol Dial Transplant. 2003; 18:2118–2121.
  22. Ball LK, Mott S. How do you prevent indented buttonhole sites? Nephrol Nurs J. 2010; 37:427–428, 431.
  23. van Loon MM, Goovaerts T, Kessels AG, van der Sande FM, Tordoir JH. Buttonhole needling of haemodialysis arteriovenous fistulae results in less complications and interventions compared to the rope-ladder technique. Nephrol Dial Transplant. 2010; 25:225–230.
  24. Nesrallah GE, Cuerden M, Wong JH, Pierratos A. Staphylococcus aureus bacteremia and buttonhole cannulation: long-term safety and efficacy of mupirocin prophylaxis. Clin J Am Soc Nephrol. 2010; 5:1047–1053.
  25. Van Eps CL, Jones M, Ng T, et al. The impact of extended-hours home hemodialysis and buttonhole cannulation technique on hospitalization rates for septic events related to dialysis access. Hemodial Int. 2010; 14:451–463.
  26. O'Brien FJ, Kok HKT, O'Kane C, et al. Arterio-venous fistula buttonhole cannulation technique: a retrospective analysis of infectious complications. Clin Kidney J. 2012; 5:526–529.
  27. Muir CA, Kotwal SS, Hawley CM, et al. Buttonhole cannulation and clinical outcomes in home hemodialysis cohort and systematic review. Clin J Am Soc Nephrol. 2013; 9:110–119.
  28. Ball LK. The buttonhole technique: strategies to reduce infections. Nephrol Nurs J. 2010; 37:473–477; quiz 478.
  29. Priyesh P, Smith K, Henner D. Effect of implementation of standardized protocol on infection rates in patients utilizing the buttonhole cannulation technique for accessing AV fistulas. Am J Kidney Dis. 2013; 61:B77.
  30. Tordoir J, Canaud B, Haage P, et al. EBPG on vascular access. Nephrol Dial Transplant. 2007; 22 Suppl 2:ii88–117.
  31. McLaughlin K, Manns B, Mortis G, Hons R, Taub K. Why patients with ESRD do not select self-care dialysis as a treatment option. Am J Kidney Dis. 2003; 41:380–385.
  32. Huynh TN, Chacko BK, Teng X, et al. Effects of venous needle turbulence during ex vivo hemodialysis on endothelial morphology and nitric oxide formation. J Biomech. 2007; 40:2158–2166.
  33. Unnikrishnan S, Huynh TN, Brott BC, et al. Turbulent flow evaluation of the venous needle during hemodialysis. J Biomech Eng. 2005; 127:1141–1146.
  34. Remuzzi A, Ene-Iordache B. Novel paradigms for dialysis vascular access: upstream hemodynamics and vascular remodeling in dialysis access stenosis. Clin J Am Soc Nephrol. 2013; 8:2186–2193.
  35. Parisotto MT, Schoder VU, Miriunis C, et al. Cannulation technique influences arteriovenous fistula graft survival. Kidney Int. 2014; 86:790–797.
  36. Sousa CN, Apóstolo JL, Figueiredo MH, Martins MM, Dias VF. Physical examination: how to examine the arm with arteriovenous fistula. Hemodial Int. 2013; 17:300–306.
  37. Jindal K, Chan CT, Deziel C, et al. Hemodialysis clinical practice guidelines for the Canadian Society of Nephrology. J Am Soc Nephrol. 2006; 17:S1–27.
  38. Ellingson KD, Palekar RS, Lucero CA, et al. Vascular access hemorrhages contribute to deaths among hemodialysis patients. Kidney Int. 2012; 82:686–692.
  39. Gill JR, Storck K, Kelly S. Fatal exsanguination from hemodialysis vascular access sites. Forensic Sci Med Pathol. 2012; 8:259–262.
  40. Almehmi A, Wang S. Partial aneurysmectomy is effective in managing aneurysm-associated complications of arteriovenous fistulae for hemodialysis: case series and literature review. Semin Dial. 2012; 25:357–364.
  41. Vanholder R, Canaud B, Fluck R, et al. Catheter-related blood stream infections (CRBSI): a European view. Nephrol Dial Transplant. 2010; 25:1753–1756.
  42. Yevzlin AS, Sanchez RJ, Hiatt JG, et al. Concentrated heparin lock is associated with major bleeding complications after tunneled hemodialysis catheter placement. Semin Dial. 2007; 20:351–354.
  43. Takla TA, Zelenitsky SA, Vercaigne LM. Effectiveness of 30% ethanol/4% trisodium citrate locking solution in preventing biofilm formation by organisms causing haemodialysis catheter-related infections. J Antimicrob Chemother. 2008; 62:1024–1026.
  44. Broom JK, Krishnasamy R, Hawley CM, Playford EG, Johnson DW. A randomized controlled trial of Heparin versus EthAnol Lock THerapY for the prevention of Catheter Associated infection in Haemodialysis patients—the HEALTHY-CATH trial. BMC Nephrol. 2012; 13:146.
  45. Gillies D, O'Riordan L, Carr D, Frost J, Gunning R, O'Brien I. Gauze and tape and transparent polyurethane dressings for central venous catheters. Cochrane Database Syst Rev. 2003:CD003827.
  46. Olson K, Rennie RP, Hanson J, et al. Evaluation of a no-dressing intervention for tunneled central venous catheter exit sites. J Infus Nurs. 2004; 27:37–44.
  47. Ravani P, Gillespie BW, Quinn RR, et al. Temporal risk profile for infectious and non-infectious complications of hemodialysis access. J Am Soc Neprhol. 20132013; 24:1668–1677.
  48. Canada Communicable Disease Report—Supplement. Infection control guidelines: Preventing infections associated with indwelling intravascular access devices. Can Commun Dis Rep. 1997; 23 Suppl 8:i–iii, 1–32, i–iv, 1–16.
  49. Ouwendyk M, Pierratos A, Francoeur R, Wallace L, Sit W, Vas S. Slow nocturnal home hemodialysis (SNHHD)-one year later. J CANNT. 1996; 6:26–28.


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Buttonhole Tract Formation Using Polycarbonate Pegs

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  • Remove the hemodialysis needles after dialysis per protocol
  • Stop the bleeding
  • Insert the peg into the established puncture sites using aseptic technique
  • Some centers recommend using topical antibiotic cream at the time of peg insertion, but not all buttonhole (BH) protocols include antibiotic prophylaxis
  • Cover the pegs with waterproof plaster dressing
  • Leave pegs in situ until the next dialysis session
  • Remove pegs immediately prior to dialysis session
  • Prepare the cannulation sites per unit protocol
  • Insert needles into site vacated by the pegs. The BH is created by approximately 8 to 12 cannulations using the peg
  • Observe for infection, dislodgement of peg, and bleeding

Criteria for Determining Type of Self-Cannulation

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For patients with arteriovenous fistulas (AVFs), rope ladder (RL) cannulation technique is the preferred cannulation method for teaching patients self-cannulation. If all indicators are check marked, initiate patient self-cannulation training using RL cannulation technique.

Adapted from Nesrallah G, Mustafa RA, MacRae J, et al. Canadian Society of Nephrology guidelines for the management of patients with ESRD treated with intensive hemodialysis. Am J Kidney Disease. 2013;5:187‒198.

Arteriovenus Fistula/Graft Audit Tool

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Tool adapted with permission from University Health Network, Toronto, Ontario, Canada.

Central Venous Catheter Audit Tool

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Tool adapted with permission from University Health Network, Toronto, Ontario, Canada.

Mupirocin Protocol: Information for Patients

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Mupirocin Nasal Ointment to Eliminate Nasal Carriage of Staphylococcus aureus

Why do I need mupirocin nasal ointment?
Recent nasal swab results have indicated that you are carrying a common type of bacteria called Staphylococcus aureus (“staph”).

This organism is often found on the skin and in the noses of healthy people where it is generally harmless. In patients who have hemodialysis (HD) access (ie, a catheter, fistula, or graft), this bacteria needs to be treated to prevent any possible spread of infection. An effective treatment to get rid of the bacteria is to apply an antibiotic ointment called mupirocin into both nostrils.

How long will treatment be required?
Treatment for 3 months is required to successfully remove the bacteria. The recommended schedule varies depending on whether you are currently on HD or have not yet started dialysis.

Where can I get the nasal ointment?
You will need to get a prescription for the ointment from your healthcare provider. The ointment can then be purchased at a pharmacy.

Technique for applying mupirocin ointment

  1. Wash hands well with soap and water or disinfect hands with alcohol gel/rub.
  2. Open the mupirocin nasal ointment tube.
  3. Place a small amount of ointment (about the side of a match head) onto a clean cotton swab and massage gently around the inside of the nostril, particularly toward the front of the nostril.
  4. Do not insert the cotton swab too deeply into the nose—no more than 1 cm inside the nostril.
  5. Using a new cotton swab, repeat for the other nostril. Using a new cotton swab will prevent contamination of the ointment tube.
  6. After applying the ointment, press a finger against the nose next to the nostril opening and use a circular motion to spread the ointment inside the nose.
  7. Wash or disinfect hands after applying the ointment.

Patients on Hemodialysis

Apply ointment inside each nostril 2 times per day for 14 days, and then continue to apply 3 times per week after dialysis on dialysis days only. Continue course for 3 months in total.

Check each box when you have applied the ointment to remind you when you need to reapply

Stage 1: Apply TWICE daily for 14 days

Stage 2: After the first 14 days, continue to apply to the inside of each nostril AFTER dialysis on dialysis days ONLY. Continue for a total of 3 months.

Ointment applied after dialysis until the following date: ________________

NOTE: It is extremely important to complete a total of 3 months of treatment. You should have a repeat nasal swab performed at your center after completing the course of therapy to ensure the therapy has been effective.

Patients Who Have Not Started Dialysis

Apply ointment inside each nostril 2 times per day for 5 days. Repeat this course of treatment each month for 3 months.

Check each box when you have applied the ointment to remind you when you need to reapply.

NOTE: It is extremely important to complete a total of 3 months of treatment. You should have a repeat nasal swab performed at your center for laboratory testing after completing the course of therapy to ensure the treatment has been effective.

Protocol adapted with permission from Metro South and Ipswich Nephrology and Transplant Services (MINTS), Queensland, Australia.

Fear of Needles

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Fear of needles is an important issue to acknowledge and address when the patient is considering home hemodialysis therapy as a treatment modality. Regardless of the cannulation technique that is being considered (rope ladder or buttonhole), instruction on self-cannulation should incorporate strategies for patients coping with fear of cannulation. Presented below are some useful strategies and techniques that can be implemented during training that may help a patient cope when learning to self-cannulate.

Coping strategies to reduce patient distress during self-cannulation

  • Staff behavior: Patience is a virtue. Staff is encouraged to modify the pace of training based on the patient’s skill and level of comfort. Staff can encourage patient involvement by asking the patient to assess the access, preparing the accessories required for cannulation, and observing the cannulation process.
  • Hand holding: Staff can help patients to slowly engage in self-care by asking them to hold the needle while the nurse cannulates the vessel.
  • Warm compress: Apply a warm compress to the access site 5 minutes prior to cannulation. This activity has 2 effects. First, the access dilates and becomes engorged, allowing for ease of cannulation. Second, the warmth of the compress is associated with comfort and relaxation.
  • Topical analgesic: Topical analgesic can be used to reduce the pain associated with needle insertion. Removing the element of pain will allow the patient to focus on self-cannulation.
  • Peer modeling: Peer support helps connect patients who are diagnosed with chronic conditions such as end stage renal disease. The chronically ill patient is not alone and can find comfort by sharing knowledge and experiences with others who are in similar situations. Peer support can improve patient self-efficacy and attitudes toward self-management.
  • Imaginal Exposure Therapy: Imaginal therapy involves the client imagining the situation until acclimatization occurs. Fears should be arranged in a hierarchy from least to most anxiety evolving. The client is encouraged to “be in the scene.” The therapist describes the event while the client describes what he or she sees, hears, tastes, smells, and feels. The client is asked to rate the level of anxiety (scale from 0‒10, where 10 is extreme) and return immediately to the scene. The session can be recorded and utilized regularly.
  • Hypnotherapy: Hypnosis can be used to encourage an individual to respond to suggestions and thus alter a habit or attitude for the benefit of health. Hypnotherapy can be used to decrease anxiety and change the patient’s reaction and attitude toward needles.
  • Medication: Medications to alleviate anxiety can be given prior to cannulation. This is a temporary measure and the prescribed medication should be limited to the initial first few cannulation events.

Patient training can become a positive experience when simple strategies are implemented to help the individual cope with fear of needles.

Useful Resources

Buttonhole Cannulation for Creation and Maintenance of Tract with Intravenous Needle and Cannula

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(Arteriovenous Fistula Only)


1 Clean towel
2 IV needle with cannula (eg, Supercath needles, 17-gauge)
3 18-gauge needles
1 Package 4 ´ 4 gauze
2 Cleansing swabsticks
1 Dressing to secure needles
2 Forceps
2 10-mL syringes prepared with 6 mL normal saline (0.9%)
1 Tourniquet
1 Alcohol wipe


  1. Wash hands and the arteriovenous fistula (AVF) with soap and warm running water for at least 20 seconds.
  2. Dry hands and the AVF with clean towel.
  3. Clean the buttonholes (BHs) with a cleansing agent. Note: Some patients find it easier to remove the scab if the BH sites are soaked with cleansing agent or saline saturated gauze. If this is the case, soak for 2 to 5 minutes.
  4. Completely remove scab on arterial BH site with 18-gauge blunt needle.
  5. Discard 18-gauge blunt needle. Do not reuse needle.
  6. Completely remove scab on venous BH site with 18-gauge needle.
  7. Discard 18-gauge blunt needle. Do not reuse needle.
  8. Clean AVF with cleaning agent again.
  9. Apply tourniquet above the AVF.
  10. Remove the IV needle with cannula needle from protector.
  11. Align IV needle with cannula at the same angel as previous cannulations, with bevel facing up over the BH site.
  12. Insert IV needle with cannula into arterial BH.
  13. Blood will backflow into needle hub.
  14. Lower the angel of the needle.
  15. Continue to advance IV needle with cannula into the AVF approximately 1 cm into blood vessel.
  16. With free hand hold the rubber adapter with thumb and forefinger, extend the thumb and pull the inner needle out of the outer needle while the palm of the same hand anchors the inner needle.
  17. Continue to advance the outer needle while continuing to withdraw the inner needle until the outer needle is treaded within the vessel completely and the outer needle is completely withdrawn.
  18. Release the tourniquet.
  19. Secure the needle with dressing.
  20. Clamp catheter with forceps.
  21. Remove rubber adapter (cap).
  22. Luer connect 10 mL syringe prepared with 6 mL normal saline to needle.
  23. Remove forceps then aspirate and flush the catheter. Assess flow.
  24. Clamp catheter with forceps.
  25. Repeat steps 9 through 24. Cannulate venous needle.
  26. Continue with dialysis initiation protocol.

Protocol adapted with permission from University Health Network, Toronto, Ontario, Canada, cannulation protocol.

Removal of Intravenous Needle with Cannula

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1 Clean towel
3 Package 4 ´ 4 gauze
2 Bandages
1 Antibacterial cream/ointment


  1. Retransfuse blood at end of treatment, per protocol.
  2. Prepare gauze with a dab of antibacterial cream/ointment.
  3. Ensure extracorporeal lines are clamped.
  4. Ensure arterial needle is clamped.
  5. Ensure venous needle is clamped.
  6. Do not disconnect extracorporeal lines from arterial and venous needles.
  7. Remove venous needle dressing.
  8. Apply gauze with dab of cream/ointment to venous needle buttonhole (BH) site.
  9. Apply gentle digital pressure to the venous BH needle site with the free hand.
  10. With access hand grip the venous blood circuit tubing between thumb and forefinger and withdraw needle completely while continuing to apply digital pressure with the free hand to BH site.
  11. Allow hemostasis to occur.
  12. Apply bandage.
  13. Remove arterial needle dressing.
  14. Repeat steps 8 through 12.
  15. Continue with end of treatment protocol.
Protocol adapted with permission from University Health Network, Toronto, Ontario, Canada, cannulation protocol.

Buttonhole Cannulation Technique with Dull (Blunt) Bevel

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(Arteriovenous Fistula Only)


1 Clean towel
2 Dull bevel buttonhole (BH) needles
3 18-gauge blunt needles
1 Package 4 ´ 4 gauze
4 Cleansing swabsticks, chlorhexidine 2%/alcohol 70%
2 Normal saline (0.9%) saturated gauze
2 Dressings to secure needles
2 10 mL-syringes prepared with 6 mL normal saline (0.9%)
1 Tourniquet
1 Personal protective equipment (eg, mask)


  1. Wash hands and the arteriovenous fistula (AVF) with soap and warm running water for at least 20 seconds.
  2. Dry hands and the AVF with clean towel.
  3. Remove dull/blunt fistula needles from package.
  4. Attach 10-mL syringe prepared with normal saline to each needle.
  5. Prime the fistula needles.
  6. Leave needle line clamps open. Set needles aside.
  7. Clean the BHs with a cleansing agent. (Note: Some patients find it easier to remove the scab if BH sites are soaked with cleansing agent or saline-saturated gauze. If this is the case, soak for 2 to 5 minutes.)
  8. Completely remove scab on arterial BH site with 18-gauge blunt needle or BH pick.
  9. Discard 18-gauge needle or discard pick. Do not reuse needle or pick.
  10. Completely remove scab on venous BH site with 18-gauge blunt needle or BH pick.
  11. Discard 18-gauge needle or discard pick. Do not reuse needle or pick.
  12. Clean AVF with cleansing agent again.
  13. Apply tourniquet above the AVF.
  14. Tighten the tourniquet.
  15. Pinch wings of dull/blunt buttonhole needle carefully, remove tip protector.
  16. Align BH needle cannula at the same angel as previous cannulations, with bevel facing up, over buttonhole site.
  17. Insert needle into established BH site at the same angle as previous cannulations.
  18. Advance BH needle along the developed tunnel tract. If mild-to-moderate resistance is met, using gentle pressure, rotate dull/blunt needle back and forth.
  19. Allow the dull/blunt needle to seek the vessel entrance, advance dull/blunt needle into the AVF.
  20. Release the tourniquet.
  21. Check the position of the needle. First, pull back blood into 10-mL syringe, then flush and check the return flow.
  22. Clamp needle.
  23. Secure the needle with dressing.
  24. Repeat steps 14 to 23 to cannulate the second needle.

Protocol adapted with permission from University Health Network, Toronto, Ontario, Canada, cannulation protocol.

Removal of Dull/Blunt Dull (Blunt) Bevel Needles from Arteriovenous Fistula

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1 Clean towel
3 Package 4 ´ 4 gauze
2 Bandages
1 Antibacterial cream/ointment


  1. Retransfuse blood at end of treatment, per protocol.
  2. Prepare gauze with a dab of antibacterial cream/ointment.
  3. Ensure extracorporeal lines are clamped.
  4. Ensure arterial needle is clamped.
  5. Ensure venous needle is clamped.
  6. Disconnect extracorporeal lines from arterial and venous needles.
  7. Remove venous needle dressing.
  8. Apply gauze with dab of cream/ointment to venous needle buttonhole (BH) site.
  9. Apply gentle digital pressure to the venous BH needle site with the free hand.
  10. With access hand grip the venous needle tubing between thumb and forefinger and withdraw needle completely while continuing to applying digital pressure with the free hand to BH site.
  11. Allow hemostasis to occur.
  12. Apply bandage.
  13. Remove arterial needle dressing.
  14. Repeat steps 8 through 12.
  15. Continue with end of treatment protocol.
Protocol adapted with permission from University Health Network, Toronto, Ontario, Canada, cannulation protocol.

Taping Method for Hemodialysis Needle

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Taping Method for Intravenous Needle with Cannula

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Heparin Locking of Central Venous Catheters

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1 Dialysis dressing pack
1 Personal protective equipment (eg, apron, gloves)
2 10-mL syringe with Leur lock
2 3-mL syringe with Leur lock
2 Sterile Leur lock caps or Tego connectors
2 18-gauge needle
2 10-mL ampules of 0.9% sodium chloride
2 Antiseptic wipe or swab (eg, isopropyl alcohol 70%/chlorhexidine 2%)
4 6 mL heparin sodium, 5000 units per 1 mL (number of ampules determined by volume of catheter, as indicated by lumen)
1 Alcohol disinfecting wipe


  1. Use alcohol wipe to clean table.
  2. Wash hands for 2 minutes. Dry thoroughly.
  3. Open supplies and place on table.
  4. Wash hands for 30 seconds and apply sterile gloves.
  5. Use the 3-mL syringes and needles to draw up the appropriate volume of heparin as indicated on the lumens of each catheter (volume varies).
  6. Ensure lines are clamped.
  7. Remove caps from lumens. Clean the end of the lumen using the antiseptic wipe or swab. Allow to dry.
  8. Connect the heparin-containing syringe to the arterial lumen and instill heparin solution. Replace cap. Repeat for venous lumen.
  9. Allow heparin solution to dwell in the lumens until the next dialysis run.
  10. Use the antiseptic wipe or swab to clean the ends of the lumens.
  11. Aspirate heparin from the lumens using a 3-mL syringe.
  12. Use the 10-mL syringes and needle to draw up sodium chloride using separate syringes for each lumen. The total volume in each syringe should be twice that of the lumen. When using Tego connectors, add 0.1 mL to volume.
  13. Flush lumens with sodium chloride solution.
  14. Perform dialysis, per protocol.
  15. Adjust postdialysis heparin bolus to account for heparin used in lock.
Protocol adapted with permission from Metro South and Ipswich Nephrology and Transplant Services (MINTS), Queensland, Australia.

Heparin Flushing of Cannulas

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  1. Cannulate the access using standard rope ladder or buttonhole protocol.
  2. Draw up 1000 units of heparin sodium using a 10-mL syringe and needle.
  3. Dilute the heparin in the syringe by drawing up sodium chloride 0.9% to a total volume of 10 mL (concentration now 100 U/mL).
  4. Flush each cannula with 5 mL (500 units) of the diluted heparin/sodium chloride solution.
  5. Flush cannulas before initiating dialysis using the usual procedure.
  6. Reduce the postdialysis heparin bolus by 1 mL (1000 units) to account for the amount used to flush the cannulas.

Note: If patients typically use enoxaparin instead of heparin, advise them to withdraw the heparinized saline from the cannulas (instead of flushing) before using them for HD. Patients should flush the cannulas with sodium chloride 0.9% to ensure proper position before initiating dialysis. Enoxaparin should be administered, as usual.

Protocol adapted with permission from Metro South and Ipswich Nephrology and Transplant Services (MINTS), Queensland, Australia.

Showering Protocol

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Required supplies

  • 2 clean face cloths
  • Clean towels
  • Mild soap with pump dispenser
  • Cleansing agent recommended by the dialysis unit (eg, chlorhexidine, povidone iodine)
  • Dressing supplies


  1. Gather all supplies and equipment before entering the shower.
  2. Ensure all catheter caps are secure before entering the shower.
  3. Remove exit site dressing, dispose of dressing, and inspect the site for signs and symptoms of infection (see below).
    • If signs and symptoms of infection are present, DO NOT USE SHOWER TECHNIQUE. Use a covered or modified shower technique. Contact your hemodialysis clinician to notify them of possible infection.
  4. While in the shower, wash and rinse face, hair, and body using 1 face cloth. The catheter area should be cleaned last.
  5. Use the second face cloth and soap to wash the area around the exit site.
  6. Rinse thoroughly and exit shower.
  7. Dry the catheter area first by gently patting with a dry towel.
  8. Dry the rest of the body using a dry towel.
  9. Apply a cleansing agent to the area nearest to the catheter and move in a circular pattern away from the catheter.
  10. Clean the catheter from the exit site to hub a second time using the cleansing agent.
  11. Allow area to dry.
  12. If necessary, apply antibiotic ointment to the area.
  13. Apply dressing.

Signs of Skin Infection

  • Redness
  • Swelling
  • Unusually warm skin
  • Fever
  • Fragile skin that bleeds easily
  • Pus or other liquid oozing from skin
  • Foul odor
  • Increased pain or change in pain
  • Cracked skin
Protocol adapted with permission from the Home Dialysis Interest Group, Toronto, Canada, document “Shower Technique for Hemodialysis Access”.

Central Venous Catheter Antibiotic Treatment Protocol

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  1. To provide evidence-based practice guidelines for the management of suspected systemic central venous catheter (CVC)‒related infection in the hemodialysis (HD) outpatient population.

    Note: This is a guideline ONLY; there may be times when, based on individual assessments, there is a need to operate outside of this protocol.

  2. To provide an accurate and comprehensive record of all vascular access infections via a single point of entry to aid in the development of targeted strategies to reduce vascular related infection rates and optimize patient outcomes.


  1. Registered nurses (RNs), graduate nurses, and licensed practical nurses (LPNs; in consultation with an RN) who have completed specialized, comprehensive HD training.
  2. Patients/designated helpers who have received specialized and comprehensive training by a trained home HD‒registered nurse may administer intravenous (IV) antibiotics at home if trained in the procedure and with dosage instructions from the home HD RN (in conjunction with this protocol).


  • Bacteremia: Presence of bacteria in the circulating blood
  • Coagulase negative Staphylococcus (Staphylococcus epidermidis): Normal bacterial skin, gut and upper respiratory tract flora. It is a true opportunistic pathogen. Infection is associated with skin penetration from CVC or peritoneal dialysis (PD) catheter insertion; implanted prosthesis (eg, heart valves); and in immunocompromised patients such as those individuals with end-stage renal disease
  • Enterococcus fecalis: Opportunistic gram-positive bacterium that has become one of the most troublesome pathogens. Lives peacefully in the gut but thrives in wounds. Extremely hardy and can survive for weeks on environmental surfaces
  • Gram-negative microorganisms: Examples are Klebsiella, Pseudomonas aeruginosa, Escherichia coli (E coli)
  • Metastatic infection: Transmission of infection from an original site to 1 or more sites elsewhere in the body
  • Sepsis: Severe and potentially fatal illness caused by overwhelming infection of the bloodstream by toxin producing bacteria
  • Staphylococcus aureus: Gram-positive microorganism that commonly colonizes the human skin and nasal mucosa. Can enter into the blood stream through breakage of the skin or may be ingested in contaminated food particles. Once in the body, it can produce poisons and toxins causing severe illness
  • MSSA: Methicillin-sensitive S aureus
  • MRSA: Methicillin-resistive S aureus
  • Streptococcus viridans: Hemolytic streptococcus that is usually the main culprit for endocardial infection


  1. A physician’s order is required to initiate the antibiotic protocol
    • When a patient presents with suspected CVC bacteremia infection, the attending nephrologist must be notified of any significant clinical findings and diagnostic testing prior to the nurse proceeding with antibiotic treatment (ie, Appendix I:“Phase I — Algorithm for SUSPECTED Systemic Catheter Associated Bacteremia”)
    • When blood culture specimen results are confirmed to be positive, the attending nephrologist will be notified of the results and the plan to continue with the antibiotic protocol (ie, Appendix II: “Phase II — Antibiotic Protocol for CONFIRMED Catheter Associated Bacteremia”)
    • Antibiotics should be prescribed in accordance with Appendix III: “Gentamycin, Vancomycin, CeFAZolin, CefTAZidime Dosing Charts”
    • If the blood culture results are negative, the antibiotic protocol will be discontinued. The attending nephrologist will be notified of the negative results and the clinical status of the patient
  2. When a patient becomes an inpatient, the attending physician will assume responsibility for management of the infection (ie, will choose to order the antibiotic protocol or provide individualized prescriptive care).
  3. The access nurse and/or designate unit-specific access expert will be notified of all suspected and/or confirmed infections.
  4. Strict aseptic technique must be used when performing CVC-related interventions.
  5. In the event of suspected catheter-related infection, patient assessment will include the following general clinical manifestations of bacteremia (see Appendix I, “Phase I — Algorithm for SUSPECTED Catheter Associated Bacteremia”).
    Note: Patients who have artificial heart valves or those who are taking steroids or immunosuppressant medications are more prone to develop systemic infection. Signs of infection include:
    • Fever ≥ 38⁰C and/or chills and rigors
    • Hypothermia
    • Confusion or altered level of mental state
    • Hyperglycemia
    • Nausea and/or vomiting
    • Complaint of general and unusual feeling of unwellness
    • Signs and symptoms of any of the following:
      • Respiratory infection (eg, cough, colored phlegm or sputum production, hemoptysis, shortness of breath, crackles and/or wheezes on auscultation, oxygen desaturation on room air, increased need for oxygen replacement)
      • Gastrointestinal infection (eg, diarrhea, abdominal cramps, loss of appetite, abdominal distention and/or tenderness)
      • Genitourinary infection (eg, hematuria, pyuria or dysuria in patients with some residual function, pain in lower back, hips or thighs)
      • Integumentary or access site infection (eg, redness, tenderness, serous or purulent exudates, pallor or bruising, cool or warm to touch, edema)
      • Metastatic infection (eg, red, tender, and/or swollen joints; new or worsening cardiac murmur, congestive heart failure)
    • Elevated white blood cell (WBC) count
  6. An RN or an LPN (in consultation with a RN), without a physician's order, may obtain the following laboratory specimens:
    • Blood culture specimens: 2 sets of 2 (4 total) or 1 set of 3 (local laboratory dependent)
    • Complete blood cell count
    • Swab(s) for culture and sensitivity from sites where exudate is present
    • Sputum and/or urine for culture and sensitivity if indicated
    • Predialysis antibiotic levels if the patient is already being treated for suspected or confirmed infection
      • If the CVC is locked with an antibiotic solution, draw antibiotic levels per PT/INR method (start dialysis, wait 5 minutes, and then draw level). Consult physician if unable to withdraw antibiotic lock solution from the CVC
      • If the predialysis antibiotic levels are not available before the patient completes the dialysis session, the next antibiotic dose can be given during the next session unless the levels are below target. In this case, it is advisable to bring the patient back for dosing. If the patient refuses or there is uncertainty (ie, close to target), check with the nephrologist
  7. Unless otherwise ordered, the patient's standard lock solution will continue to be used. Note: There may be some situations where the physician requests use of vancomycin/heparin OR cefTAZidime/heparin lock solution (to replace the patient’s standard lock solution).
  8. Antibiotics will be adjusted based on the following predialysis antibiotic levels:
    • Vancomycin greater than 19 mg/L: Hold vancomycin
    • Gentamicin less than 1.5 mg/L or greater than 3 mg/L: refer to Appendix III. Gentamycin, Vancomycin, CeFAZolin, CefTAZidime Dosing Charts
    Note for home HD patients: Alternatively, vancomycin 25 mg/kg load followed by 500 mg every HD session to a maximum of 4 sessions/week, may be given without pursuing vancomycin levels.


  • Patients must be educated on the signs of CVC access infection and the need to seek immediate medical attention in urgent or emergent situations (eg, septicemia)
  • Antibiotic doses may be verified by 2 nurses (1 must be a RN) or 1 nurse and 1 pharmacist at the discretion of the RN

PROCEDURE for Antibiotic Lock Preparation (refer to Appendix II — “Phase II Antibiotic Protocol for CONFIRMED CVC Associated Bacteremia According to Bacterial Organism”):

  1. Prepare vancomycin and heparin lock solution, if ordered, for CVC Locks: Note: Vancomycin lock solution should be prepared immediately prior to administration as it is good for 72 hours only (this will ensure potency is maintained within the catheter lumen until the next run). Also note that prevancomycin levels may be influenced by the vancomycin/heparin lock solution and unusual results should be brought to the attention of the physician.
    1. Gather equipment/supplies
      • Vancomycin 500-mg vial
      • Sterile water for reconstitution
      • Heparin 10,000-U/mL vials
      • Sodium Chloride 0.9% 50 mL minibag
      • Needles, 18 gauge ´ 5
      • Syringes, 3 mL ´ 3; 10 mL ´ 4
      • Medication labels, if required
    2. Prepare vancomycin 2.8 mg/mL

      • Add 10 mL sterile water for injection to a 500-mg vial of vancomycin powder to make a 50-mg/mL solution
      • Shake to dissolve
      • Withdraw and discard 4 mL from a 50-mL minibag of sodium chloride 0.9% (this is the standard average overfill in a minibag)
      • Inject 3 mL (150 mg) of vancomycin into the minibag and apply medication label
      • Final concentration: 150 mg in 53 mL = 2.8 mg/mL vancomycin
    3. Prepare heparin lock solution

      • Into a 3-mL syringe, draw 0.3 mL (3000 units) from a 10,000-U/mL vial of heparin
      • Using the same syringe, withdraw 2.7 mL (7.5mg) of vancomycin from the above minibag
      • Repeat above 2 steps, using a second 3-mL syringe
      • Flush both lumens with 10-mL sodium chloride 0.9%
      • Instill vancomycin/heparin lock solution equal to the volume of CVC lumens
      • Apply medication labels to the lumens
    4. Final products (reflected on medication label)

      • Vancomycin 7.5 mg/3 mL= 2.5 mg/mL
      • Heparin 3000 units/3 mL=1000 U/mL
  2. If cefTAZidime/heparin lock is ordered
    For inpatients: Order from pharmacy
    For outpatients: Mix as follows (prepare immediately prior to administration).

    1. Gather equipment/supplies

      • CefTAZidime 1-g vial
      • Heparin 10,000-U/mL vials
      • Sterile water for injection 10 mL
      • Sodium chloride 0.9% 50-mL minibag
      • Needles, 18 gauge ´ 5
      • Syringes, 10 mL ´ 4; 3 mL ´ 3; 1 mL ´ 1
      • Syringe-to-syringe transfer device ´ 2
      • Medication labels
    2. Reconstitute cetTAZidime

      • Inject 4.4 mL sterile water for injection to 1-g vial of cefTAZidime
      • Shake well to reconstitute
      • Yields a 200-mg/mL solution
    3. Prepare lock solution

      • Draw up 0.25 mL (50 mg) cefTAZidime
      • Draw up 2.5 mL (25,000 units) heparin using the 10,000-U/mL solution
      • Using a syringe-to-syringe transfer device, transfer the contents of both syringes to a 10-mL syringe
        • Fill this final syringe to 10 mL using sodium chloride 0.9%
        • Mix well
        • Using syringe-to-syringe transfer device, fill 2, 3-mL syringes with cefTAZidime/heparin lock solution
        • Flush both lumens with 10 mL sodium chloride 0.9%
        • Instill cefTAZidime/heparin lock solution equal to the volume of CVC lumens
        • Apply medication labels to lumens
      • Final product (reflected on medication label):
        • CetTAZidime 5 mg/mL + heparin 2500 U/mL lock solution


  1. Allon M. Dialysis catheter related bacteremia: Treatment and prophylaxis. Am J Kidney Dis. 2004;44:779‒791.
  2. Allon, M. Saving infected catheters, why and how? Blood Purif. 2005;23:23‒28.
  3. Ariano RE, Fine A, Sitar DS, Rexrode S, Zelenitsky SA. Adequacy of vancomycin dosing regimen in patients receiving high flux hemodialysis. Am J Kidney Dis. 2005;146:681‒687.
  4. Chiou et al. Antibiotic lock technique reduces the incidence of temporary catheter related infections. Clin Nephrol. 2006;65:419‒422.
  5. CSN Hemodialysis Clinical Practice Guidelines. J Am Soc Nephrol. 2006;17:S1‒27.
  6. Falk A, Prabhuram N, Parthasarathy S. Conversion of temporary hemodialysis catheters to permanent hemodialysis catheters. Semin Dial. 2005;18:425‒430.
  7. Jaber BL. Bacterial infections in hemodialysis patients: Pathogenesis and prevention. Kidney Int. 2005;67:2508‒2519.
  8. Mokrzycki MH, Zhang M, Cohen H, Rosenberg S. Tunnelled hemodialysis catheter bacteremia: risk factors for bacteremia: recurrence infections complications and mortality. Nephrol Dial Transplant. 2006;21:1024‒1031.
  9. Poole CV, Carlton D, Bimbo L, Allon M. Treatment of catheter related bacteremia with an antibiotic lock protocol: effect of bacterial pathogen. Nephrol Dial Transplant. 2004;19:1237‒1244.
  10. Tanriover B, Carlton D, Saddekni S. Bacteremia associated with tunneled dialysis catheters: comparison of two treatment strategies. Kidney Int. 2000;57:2151‒2155.
  11. Vercaigne LM, Ariano RE, Zacharian JM. Bayesian pharmacokinetics of gentamycin in a hemodialysis population. Clin Pharmacokinet. 2004;43:205‒210.
  12. Zipporah K, et al. Management of hemodialysis catheter related bacteremia with an adjunctive lock solution. Kidney Int. 2002;61:1136‒1142.

Protocol adapted with permission from Southern Alberta (Canada) Renal Program, Alberta, Canada.

Alteplase Use in Hemodialysis Central Venous Catheters

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To use a fibrinolytic agent to restore and maintain patency of occluded hemodialysis (HD) central venous catheters (CVCs). This may involve 1 or both lumens of the CVC.


  1. This procedure may be done on tunneled or nontunnelled CVCs, but only with a physician’s order.
  2. Strict aseptic technique is to be used when performing this procedure.
  3. The reconstituted product must be carefully inspected for particulate matter and not administered if it is present. To minimize risk, a 5-μm filter needle must be used to withdraw the reconstituted product from the vial prior to patient administration.
  4. Before alteplase use, the CVC should be thoroughly evaluated to determine other causes of occlusion and/or inability to sustain required flows.
  5. Indications of CVC malfunction include:
    • Difficulty aspirating and/or infusing
    • Inability to maintain a sustained blood flow rate (QB) > 250 mL/min for 2 consecutive HD sessions
    • Inability to initiate a QB > 200 mL/min for 1 HD session
    • Arterial pressure of ≤ ‒250 mm Hg and/or venous pressures of ≥ 250 mm Hg
    • Line reversal to achieve QB > 250 mL/min
  6. All efforts should be made to limit a maximum of 2 doses of alteplase within a 2-week time period and/or a maximum allotment of 4 mg per dialysis session. If this has occurred, the patient’s primary nephrologist should be notified and CVC viability should be assessed.
    • Note: Alteplase should not be ordered for CVCs that have been placed within 1 week, as problems related to occlusion of CVCs during this period are likely a result of mechanical problem; therefore, line exchange should be considered
  7. All patients whose lumens are routinely locked with alteplase (indication for this is rare)
    • Will receive 1 mg per lumen of alteplase lock solution
    • Will be assessed by the vascular access team and primary nephrologist for other potential alternatives

Points of Emphasis

  1. Alteplase contains no antibacterial preservatives and should be reconstituted immediately before use. Reconstituted solution may be used within 24 hours after reconstitution if stored in the refrigerator.
  2. Relative contraindications to alteplase include
    • Recent (within 2 months) central nervous system surgery or severe trauma
    • Known active internal bleeding
  3. Lyophilized (not reconstituted) alteplase should be stored at refrigerated temperature
  4. No other medications should be added to solutions containing alteplase


  • On/off supplies
  • 3-mL syringes
  • 10-mL prefilled normal saline (0.9%) syringes
  • Blunt fill needles
  • Gauze (4 ´ 4)
  • Two 5-μm filter needles
  • Alteplase 2-mg vial
  • Sterile water for injection
  • Labels for syringes


  1. Evaluate and troubleshoot the patency of the catheter as instructed in the Appendix “Alteplase Algorithm”.
  2. If indicated, obtain physician’s order for alteplase administration, verifying the method of administration.
    • 30-minute dwell (for lumen occlusion)
    • Intravenous infusion (for sluggish flow)
    • Lock
  3. Obtain alteplase and reconstitute as follows:
    • Reconstitute the 2-mg vial of alteplase with 2.2 mL sterile water for injection (result is 1 mg/mL alteplase)
    • Inject the sterile water into the 2-mg alteplase vial, directing the diluent stream into the powder. Slight foaming may occur; allow the vial to stand undisturbed until large bubbles have dissipated
    • Mix by gently swirling the vial until the contents are completely dissolved. DO NOT SHAKE
    • Inspect the product for foreign matter and discoloration. The reconstituted 2 mg alteplase preparation should appear as a colorless to pale yellow transparent solution
  4. Explain the procedure to the patient. Obtain baseline vital sign measurements and document them in the patient chart.
  5. Instill the alteplase solution as follows:
    • 30-minute dwell
      • Note: If resistance is felt at any time, use a gentle push/pull motion to instill the lumen. Never use excessive force
      • Using a 5-μm filter needle, withdraw 1 mL reconstituted alteplase (1 mg) into 2 separate 3-mL syringes. Apply alteplase labels to the syringes
      • Using 2 additional 3-mL syringes, withdraw normal saline solution equal to the remaining volume of each lumen plus 0.9 mL (used to advance alteplase)
      • Instill 1-mL alteplase solution (1 mg) into each lumen
      • Instill normal saline equal to the volume of each lumen, then advance alteplase by 0.3 mL (0.6 mL will be left in each syringe)
      • Clamp lumens, leaving syringes attached. Wait 10 minutes
      • Advance alteplase by 0.3 mL using saline solution (0.3 mL will be left in each syringe)
      • Clamp lumens and leave syringes attached. Wait 10 minutes
      • Advance alteplase using the last 0.3 mL of saline. Clamp lumen. Wait 10 minutes
      • Use prefilled 10-mL normal saline syringes to briskly flush and aspirate each lumen to assess function
      • If unable to flush or withdraw alteplase, attempt to reposition the patient and ensure the catheter is not kinked. Attempt again to flush with 10 mL normal saline
    • Intravenous infusion
      • Use a 5-μm needle to withdraw 2 mL reconstituted alteplase (2 mg) into a 3-mL syringe
      • Add 2 mg alteplase to a 50-mL minibag of 0.9% normal saline solution
      • Attach minibag to the infusion pump, and then to the venous chamber of the blood line
      • Infuse alteplase over 1 hour (rate of 50 mL/h) as follows:
        • With the CVC lumens in the “reverse” position for the first 30 minutes
        • With the CVC lumens in the “normal” position for the last 30 minutes. If unable to infuse in the “normal” position, administer the last 30 minutes in the “reverse” position
    • Alteplase lock
      • Use a 5-μm needle to withdraw 1 mL reconstituted alteplase (1 mg) into 2 separate 3-mL syringes
      • Using 2 additional 3-mL syringes, withdraw normal saline equal to the remaining volume of the lumen plus 0.2 mL each (used to advance alteplase)
      • Instill alteplase 1 mL (1 mg) into each lumen
      • Instill normal saline equal to the remaining volume of each lumen, then advance alteplase by 0.2 mL
      • Clamp lumen, apply injection clamps, and apply alteplase labels to the lumens
      • Allow alteplase to dwell in the lumens until the next HD treatment
  6. If catheter is patent, commence dialysis and administer heparin as prescribed.
  7. If catheter is patent and the heparin lock solution has been flushed through the catheter, commence dialysis but do not administer heparin bolus as prescribed.
  8. If the alteplase procedure (30-minute dwell or infusion) was performed at the end of dialysis or on a nondialysis day, flush the lumens with 10 mL 0.9% saline and lock with anticoagulant.


  • Allon M. Current management of vascular access. Clin J Am Soc Nephrol. 2007;2:786‒800.
  • BC Renal Agency. Vascular Access Guideline. Alteplase use for occluded hemodialysis catheters. Updated March 4, 2011. Available at: www.bcrenalagency.ca/sites/default/files/documents/files/Use-of-Alteplase-FINAL-March-4-2011.pdf. Accessed June 9, 2014.
  • Beathard GA. Catheter thrombosis. Semin Dial. 2001;14:441‒445.
  • Cathflo® Activase® (alteplase) [package insert]. South San Francisco, CA: Genentech, Inc; 2005.
  • Daugirdas JT, Blake PG, Ing TS. Handbook of Dialysis, Volume 236. 4th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.
  • Deitcher SR, Fesen MR, Kiproff PM, et al. Safety and efficacy of alteplase for restoring function of occluded central venous catheters: results of the cardiovascular thrombolytic to open occluded lines trial. J Clin Oncol. 2002;20:317‒324.
  • Dinwiddie LC. Managing catheter dysfunction for better patient outcomes. Nephrol Nurs J. 2006;31:653‒660, 671.
  • Jindal K, Chan CT, Deziel C, et al. Hemodialysis clinical practice guidelines for the Canadian Society of Nephrology. J Am Soc Nephrol. 2006;17(Suppl 1):S4‒27.
  • National Kidney Foundation. KDOQI Clinical Practice Guidelines for Vascular Access, Update 2006. Available at: http://www2.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/. Accessed June 06, 2014.
  • Ponec D, Irwin D, Haire WD, et al. Recombinant tissue plasminogen activator (alteplase) for restoration of flow in occluded central venous access devices: a double-blind placebo-controlled trial–the Cardiovascular Thrombolytic to Open Occluded Lines (COOL) efficacy trial. J Vasc Interv Radiol. 2001;12:951‒955.

Protocol adapted with permission from Southern Alberta Renal Program, Alberta, Canada.

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