Arteriovenous fistula cannulation in haemodialysis patients

The study has been designed to determine the primary and secondary AVF patency rates at 1 year and the complication rate for each cannulation method.

Parameters to be measured:
1. 1 year AVF primary and secondary patency rates
2. AVF complication rate - haematoma formation, aneurysm formation, surgical or radiological interventions (i.e., stenoses), scar tissue, missed needles, skin infiltration, steal syndrome, clotted AVF, infection, bleeding time post needle removal, neurologic disorder, and frequency and duration of hospital admissions
3. Time to cannulation (i.e speed of setting up dialysis) (at each haemodialysis session). The speed with which a dialysis session is commenced is very important to a patient. They are usually on dialysis for at least 4 hours with extra time needed for travelling in from home, waiting to go on the haemodialysis machine, being cannulated for dialysis, coming off dialysis and then travelling home again. This makes it at least a 6 hour session three times a week – any minutes saved have an important impact on the patient!
4. Cannulation pain as measured by a validated visual analogue pain score and use of local anaesthetic. The Royal Berkshire Pain Chart was developed in 1992. The development of the pain tool was led by the Pain Forum in collaboration with the Practice Development Team and Dr. John Mackenzie (Pain Consultant) and included an extensive literature search, Delphi technique and then piloting on surgical, orthopaedic and medical wards within this Trust. The tool took at least two years to develop. The pain tool formed an important part of the pain point prevalence study (Trust-wide study) (1994) and (1995). Cannulation pain will be recorded at each dialysis session and is expected to take less than 1 minute to complete.
5. Economic analysis for each cannulation method
6. Nurse and patient satisfaction with each method
7. Clinical history: a record of medication including erythropoietin dose and ACEI usage, participant age and sex, site of AVF, previous vascular access procedures, date AVF was first needled and history of diabetes mellitus or ischaemic heart disease
8. Clinical parameters (already measured as part of routine clinical practice): adequacy of haemodialysis prescription (Kt/v), intra-dialytic haemodialysis monitoring (blood flow, Litres of blood processed, BP, AVF venous and arterial pressures) and blood parameters: Hb, C-reactive protein, haematocrit and cholesterol.

These parameters will be assessed by:
1. Review of participant's medical notes and medication lists (also recorded on the Renal Unit PROTON computer system)
2. At each dialysis session:
2.1. Cannulation pain score (patient time less than 1 minute)
2.2. Assessment by nurse and record kept:
2.2.1. Missed needle
2.2.2. Skin infiltration
2.2.3. Haematoma formation
2.2.4. Need for local anaesthesia
2.2.5. Time to cannulation
2.2.6. Bleeding time post needle removal
3. Monthly assessment (as per existing unit practice – nothing in addition except for monthly AVF photograph):
3.1. Blood tests as per normal Renal Unit practice (no additional blood tests being performed for participants in the trial). Any changes made to a participant's medication or haemodialysis prescription in response to these results would be made as part of our standard practice and guided by existing protocols by any member of the Renal Unit Multidisciplinary team.
3.2. Transonic ultrasound access blood flow monitoring (as per existing unit practice). Referral made for surgical or radiological intervention as per Unit protocol if indicated by results.
3.3. Monthly photograph of AVF (with a ruler measurement) – to assess scar tissue and aneurysm formation
4. Record made over the 1 year period:
4.1. Any radiological or surgical intervention for: Significant stenosis or clotted AVF
4.2. Frequency and duration of hospital admissions
4.3. Nurse preference for cannulation type
4.4. Infection: exit site or blood
4.5. Fistula failure - need for tunnelled dialysis catheter for haemodialysis

No secondary outcome measures