Arteriovenous Fistula Cannulation Research Articles

Applying Cryotherapy and Balloon Inflation Technique to Reduce Pain of Arteriovenous Fistula Cannulation among Children Undergoing Hemodialysis

Children undergoing hemodialysis are exposed to stress and pain from approximately 300 punctures per year to their arteriovenous fistula(AVF). Relieftheir pain sensation improves their acceptance of the procedure and consequently improves their quality of life. Aim:The study aimed to investigate the effect of cryotherapy and balloon inflation on reducing pain of arteriovenous fistula cannulationamong children undergoing hemodialysis. A quasi-experiment design was performed.Setting: The study was conducted in the hemodialysis unit in Mansoura University Children's Hospital.Subjects: All available children (n = 45 children) undergoing HD with AVF for a period of 3 months at the previously mentioned setting.Tools: Four tools were used for data collection: A Structured Interview Sheet,Physiological Measurements Tool, Pain Behavioral Observational Checklist and Numerical pain rating scale. Results:There is a highly statistical significance difference between mean scores of observed behavioral response to pain and pain intensity among hemodialysis children across pre intervention, cryotherapy and balloon inflation before and immediately after AVF punctures. Conclusion: The study concluded that, cryotherapy and balloon inflation have a positive effect on reducing pain of arteriovenous fistula cannulation among children undergoing hemodialysis. Recommendations:Cryotherapy and balloon inflation should be utilized as a routine care in the routine care for hemodialysis children to relieve needle puncture pain.

Percepción del dolor según el modo de punción de la fístula arteriovenosa en pacientes sometidos a hemodiálisis. Revisión sistemática

Objetivo: Valorar la posible asociación entre la forma de punción de la fístula arteriovenosa y el dolor que siente el paciente por la inserción de la aguja. Metodología: Se ha seguido la declaración PRISMA para revisiones sistemáticas. Se han consultado 6 bases de datos; Medline, Scopus, Cuiden, CINAHL, SciELO, y Cochrane PLUS. Además, se realizó una búsqueda secundaría manual para detectar literatura gris no encontrada en las bases de datos o mediantes las estrategias definidas. Criterios de inclusión; estudios de nivel de evidencia 1 en la escala Scottish Intercollegiate Guidelines Network, publicados en los últimos 10 años, idiomas español/inglés, y temática relacionada con las técnicas utilizadas en hemodiálisis para el abordaje de la fistula. Los artículos se evaluaron de forma crítica para detectar cualquier riesgo de sesgo mediante el instrumento CASPe y el manual Cochrane para Revisiones Sistemáticas de Intervenciones. Resultados: Se identificaron un total de 150 resultados, seleccionándose finalmente 9 estudios. Los resultados han sido muy heterogéneas, encontrándose resultados para el dolor, tasas de infección, número de intentos de canalización, flujo sanguíneo, presión venosa, tiempo de hemostasia, seguridad, dilataciones aneurismáticas, estética del brazo portador de la fístula y calidad de vida del paciente. Conclusiones: La evidencia no respalda el uso preferencial de la técnica del ojal sobre la canalización tradicional. Por tanto, se necesita mejorar el rigor metodológico y un mayor tamaño muestral para dilucidar que técnica da mejores prestaciones respecto al dolor, permitiendo por tanto mejorar la calidad de vida de los pacientes de hemodiálisis.

Analogy and collation of Valsalva manoeuvre and Ball compression on pain during arteriovenous fistula cannulation in patient with chronic renal failure on haemodialysis

Analogy and collation of Valsalva manoeuvre and Ball compression on pain during arteriovenous fistula cannulation in patient with chronic renal failure on haemodialysis - IJCAP- Print ISSN No: - 2394-2118 Online ISSN No:- 2394-2126 Article DOI No:- 10.18231/2394-2126.2019.0016, Indian Journal of Clinical Anatomy and Ph

One-stage operation for superficialization of native radio-cephalic fistula in obese patients.

The population of obese patients is increasing in general and also at hemodialysis initiation. For successful cannulation of arteriovenous fistula, the National Kidney Foundation-Dialysis Outcome Quality Initiative guidelines suggest that the required maturation parameters are at a depth of <6 mm. There are several reports describing two-stage superficialization of arteriovenous fistulas in obese cases. Therefore, we investigated the utility and complications of one-stage superficialization of radio-cephalic fistula. From January 2011 to March 2017, we simultaneously performed forearm radio-cephalic fistula creation and superficialization of the cephalic vein for 10 patients having obesity (body mass index > 30 kg/m2) and deep cephalic vein (>6 mm). Initially, an arteriovenous anastomosis was created at an appropriate site. Subsequently, an 8-10 cm longitudinal skin incision was made along the lateral aspect of the forearm cephalic vein. The cephalic vein was identified and exposed. The cephalic vein was repositioned superficially. The mean age of the patients was 53 years (range: 40-72 years) and the mean body mass index was 40.2 kg/m2 (33.1-59.7 kg/m2). The cause of renal failure in eight patients was diabetic nephropathy, and in two patients, it was unknown. After the procedure, vein depth became 3.4 mm (1.9-4.6 mm) from 8.2 mm (6.0-13.4 mm). All patients who initiated dialysis underwent successful two-needle cannulation. Primary patency rate was 71.4% at 12 months (two patients underwent percutaneous transluminal angioplasty) and secondary patency rate was 100%. There was one procedure-related complication and delayed wound healing, which was improved by observation without antibiotics. This small series of patients indicates that one-stage superficialization of radio-cephalic fistula is a safe and effective option to start hemodialysis in obese subjects.

Resection of puncture site necrosis over an arteriovenous fistula: Endoclamp use for preservation of cannulation sites

Skin necrosis overlying an arteriovenous fistula at the cannulation site is a common and potentially life-threatening problem, often associated with underlying aneurysm formation. Arteriovenous fistula-skin necrosis generally requires resection of surrounding skin margins and the underlying aneurysmal vessel wall, allowing repair with healthy tissue of the arteriovenous fistula in addition to closure of soft tissue and skin. In patients with insufficient fistula length, salvage of these arteriovenous fistulas may result in difficult or insurmountable cannulation issues leading to attempts at one-needle cannulation dialysis or, most often, catheter placement. Pre-existing stents or extensive calcification may add to the technical challenge of gaining proximal and/or distal control. We describe our technique for dealing with such arteriovenous fistula-skin necrosis lesions utilizing endo-occlusion with an angioplasty balloon for vascular control, allowing a limited incision and tissue resection with preservation of arteriovenous fistula cannulation length.

Targeted tumescent liposuction for fistula superficialization

Obesity poses problem with the cannulation of arteriovenous fistula and difficulty in establishing functional autogenous access for hemodialysis. We describe a case where we used targeted tumescent liposuction to remove subcutaneous fat over the fistula.

Autologous arteriovenous fistulas for hemodialysis using microsurgery techniques in children weighing less than 20kg.

This study aimed to describe the efficiency and longevity of arteriovenous fistula (AVF) for hemodialysis (HD) in children weighing ≤20kg. We collected data of all AVFs created using microsurgery techniques between 1988 and 2015. Success was considered as the ability to use the AVF for HD. Primary and secondary patency rates were measured. Forty-eight AVFs (35 forearm, 13 upper arm) were created in 41 children with a median weight of 13.5kg (range 5.5-20). The need for a second AVF was significantly higher in younger and thinner children at the time of AVF creation (p = 0.046 and p = 0.019, respectively). Successful use for HD occurred in 42 AVFs (87.5%), while six (12.5%) resulted in failure for early thrombosis or nonmaturation. Median time to first cannulation was 18.8weeks (range 2-166.3). Primary and secondary patency rates at 1, 5, and 10-year follow-ups were 54.2%, 29.2%, and 13.7%; and 85.4%, 57.7%, and 33%, respectively. Almost one third of thromboses after first AVF cannulation were observed at kidney transplantation (KT) perioperatively. At the end of the follow-up (median duration 5.07years, range 0-17.95), one patient was still on HD via AVF, two died of unrelated reason, and 38 were transplanted-one of whom returned to HD with a new AVF. AVF using microsurgery techniques is feasible in young children, showing an early failure rate of 12.5%. Time to first cannulation may be rather long, but secondary patency is excellent. Thrombosis rate is high during KT.

Efficacy of application of eutectic mixture of local anesthetics and lidocaine spray in pain management of arteriovenous fistula cannulation in hemodialysis patients

Introduction: The hemodialysis patients frequently experience the pain and anxiety induced by arteriovenous fistula (AVF) cannulation. This painful intervention, if repeated, imposes destructive psychosomatic effects on patients. Hence, the use of appropriate procedures to reduce pain in these patients is of utmost importance. Objectives: The present study aimed at investigate efficacy of lidocaine spray and topical eutectic mixture of local anesthetics (EMLA) cream in releiving pain induced by arteriovenous fistula cannulation in hemodialysis patients. Patients and Methods: This quasi-experimental study was conducted on 40 patients with arteriovenous fistula (AVF) selected on the basis of purposive sampling method in 2015 in hemodialysis ward of Shahid-Sadoughi hospital. Pain severity was measured at AVF cannulation using EMLA analgesic cream and lidocaine spray with the pain severity numerical scale. Repeated measures analysis of variance (ANOVA) was used in data analysis using SPSS 16. Results: Findings showed that the mean scores of the three methods of pain management, i.e., no pain control method, lidocaine spray, and EMLA analgesic cream, were 7.45±0.88, 4.22±1.33, and 2.8±0.70, respectively. There was a considerable reduction in pain severity using the lidocaine spray and EMLA analgesic cream compared to the conventional method (P<0.001). EMLA analgesic cream caused a greater reduction in pain rate compared to lidocaine spray (P<0.001). Conclusion: This study suggested that EMLA analgesic cream was more effective in reducing pain caused by AVF cannulation. Hence, it is recommended that the hemodialysis patients apply EMLA analgesic cream themselves at the time of the procedure to reduce the cannulation pain.

Impact of arteriovenous fistula cannulation on the quality of dialysis.

Adequate hemodialysis directly improves health. Puncturing an arteriovenous fistula (AVF) and the amount of blood recirculation greatly affect the quality of dialysis. Few studies have assessed the method to cannulate a fistula and its influence on efficiency of hemodialysis. This prospective pilot study included 14 patients with end-stage renal failure receiving regular intermittent hemodialysis. Patients received three consecutive treatments with both needles directed upstream then three consecutive treatments with the venous needle directed upstream and the arterial needle directed downstream. With both techniques, the distance between the needles was kept constant at 2.5 cm. Recirculation rate and Kt/V ratio were measured during each treatment using thermodilution and a diascan Fresenius generator. The 14 patients received 84 hemodialysis sessions: i.e., 8 (57.1%) males and 6 (42.8%) females, mean age 62.3 ± 15.57 years. Results showed that mean recirculation rates and Kt/V did not significantly differ between the two techniques. Because no significant difference was found between the two techniques, the direction of insertion of needles should be decided upon on a case-by-case basis depending on the anatomy of the AVF and the feasibility of the puncture.

Is early cannulation of an arteriovenous fistula associated with early failure of the fistula?

To study the effect of early cannulation of arteriovenous fistulas (AVF) on early AVF failure. Analysis of two databases of access operations and dialysis sessions from 1/12/2002 till 1/4/2015. Follow-up until 1/4/2016. Functional dialysis use defined as six consecutive cannulations of the AVF with two needles. Early cannulation defined as needling of the AVF within 30 days of creation. Early failure was defined as abandonment for new form of access within 90 days of first cannulation. Machine blood-flow rates (BFR) of each dialysis session for the first 2 months collected from the dialysis database. We analysed 1167 AVFs with functional dialysis use. Some 148 AVFs (11%) were needled within 30 days. Early needling was not associated with increased early failure rates (p = 0.43). Early failure rates were lower in AVFs with six consecutive successful cannulations from the start (p = 0.002). There was a trend of reduced early failure rates (test for trend: p = 0.018) in the latter years of the study period, but no trend in early cannulation rates (p = 0.19). Failure to achieve six successful cannulations from the start was an independent predictor of early AVF failure but early needling was not an independent predictor in multivariate analysis. Average starting BFRs were higher in AVF that were needled early. Early cannulation was not associated with early failure. Failure to achieve six successful cannulations from the start was an independent predictor of early failure. The trend in yearly variation of early failure rates suggests that evolving practices influenced early failure rates.

Studio Pilota Randomizzato Controllato: Protocollo Sperimentale Sugli Effetti di Una Medicazione a Rilascio D'argento in Pazienti Incannulati Con Tecnica Buttonhole

Abstract non disponibile (nursing)

Coronal mode ultrasound guided hemodialysis cannulation: A pilot randomized comparison with standard cannulation technique.

Infiltrations from cannulation result in significant morbidity including loss of hemodialysis (HD) vascular access (VA). Cannulation is dependent on personnel skill and VA characteristics. Surface marking of VA lacks real-time information and traditional ultrasound (US) devices are large, expensive, requiring skilled operators. Sonic Window© (Analogic Ultrasound, Peabody, MA, USA) is a coronal mode ultrasound device (CMUD) approved for VA cannulation. Single center randomized, prospective pilot study comparing handheld US-guided cannulation of new arteriovenous fistula (AVF) to standard cannulation practices. Patients with end stage renal disease (ESRD) on in-center HD who had a new AVF cleared for cannulation and dialysis were enrolled. Patients with new AVF received either standard cannulation (control group) or image guidance using CMUD (study group) for 3 weeks. Ultrasound characteristics of VA, cannulation practices and complications end points were obtained. An infiltration rate of 9.7% was noted during the study. Slightly lower odds ratio (OR) of infiltration was observed in the study group (OR 0.94, 95% CI: 0.26-3.41, P value = 0.93). Study group yielded longer time for assessment (101.8 ± 80.2 vs. 22.3 ± 22.5 seconds, P = < 0.001), increased cannulation time (41.1 ± 70.6 vs. 25.0 ± 27.9 seconds, P = 0.04), and increased patient satisfaction (94.6% vs. 82%, P = 0.04) compared to control group. Number of cannulation attempts, needle size, arterial or venous needle insertion, and tourniquet usage between groups were not statistically different. Handheld ultrasound is a safe and useful aid in cannulation of dialysis access.

Cryotherapy intervention in relieving arteriovenous fistula cannulation-related pain among hemodialysis patients at the King Khalid Hospital, Tabuk, Kingdom of Saudi Arabia.

Pain during arteriovenous fistula (AVF) cannulation remains a common problem in hemodialysis (HD) patients that leads to noncompliance to lifetime maintenance HD. This study was performed to determine the effect of cryotherapy on reducing pain during AVF cannulation among HD patients in the King Khalid Hospital, Tabuk, Kingdom of Saudi Arabia. This is an experimental study which included 62 patients undergoing HD through an AVF. Randomization was used to assign the patients into the experimental (received cryotherapy) and control (no cryotherapy) groups. The Arabic version of Wong-Baker pain rating scale was used to determine the pain score. There was a significant difference in the pre-and post-intervention pain scores among the experimental group, while there was no such difference in the control group. The null hypothesis was rejected based on a P <0.05. Our study suggests that cryotherapy intervention to relieve AVF cannulation-related pain among adult patients undergoing HD is effective. Therefore, it is recommended that cryotherapy should be considered as a complementary intervention to reduce pain related to AVF cannulation.

The evaluation of Valsalva maneuver on pain intensity within the needle insertion to the arteriovenous fistula for patients undergoing hemodialysis in the selected hospitals in Isfahan in 2015

Introduction: Pain is an unpleasant feeling and it is called as the fifth vital sign. Fistula cannulation in hemodialysis patients is a very stressful and painful process. Nurses can help relieve pain with the use of nonpharmacological pain management therapies, independently. This study conducted aimed to investigate and determine the effect of Valsalva maneuver on pain intensity during cannulation of arteriovenous fistula (AVF) in patients undergoing hemodialysis. Materials and Methods: This study was conducted on 35 hemodialysis patients who were selected by convenience sampling in two Amin Medical Center and Hazrat-e Zahra-e Marziye Hospital in Isfahan. Data collection was performed using an interview questionnaire developed by the researcher, Abbey pain scale, and numerical pain rating. Data analysis was done using the descriptive and analytic tests in SPSS Software Version 20. Results: Paired t-test results showed that the score average of objective and subjective pains was reduced significantly after intervention compared to before that (P

Plastic Cannula use in Hemodialysis Access

Successful cannulation of arteriovenous fistula (AVF) or arteriovenous graft (AVG) is an important concept in hemodialysis. Metal needles have been used for cannulation in dialysis for over 50 years. Plastic cannula for dialysis is currently being introduced into Australia. To identify if the implementation of plastic cannula could decrease the amount of miscannulations and adverse events in AVFs at first cannulation. Train all staff in the Barwon Health renal department in the new technique of plastic cannula insertion and implement a new protocol for cannulation of AVFs in the first two weeks of dialysis. The training process took 12 months longer than anticipated due to issues with 'expert' to 'novice' reservations from staff, but initial results are positive with the statewide key performance indicator of new patients using AVF at first dialysis rising from 50% in 2013 to 78% in 2015. Staff were significantly more successful cannulating with plastic cannula in patients who had AVF only (67% success) than those who had a CVC alternative (24% success). Plastic cannulas offer a new and innovative way to cannulate AVFs and with time, expertise and training can be utilized to provide a successful cannulation program for patients starting hemodialysis with AVFs.

The efficacy and durability of the Venous Window Needle Guide implanted on uncannulatable arteriovenous fistulas

The Venous Window Needle Guide (VWING; Vital Access Corp, Salt Lake City, Utah) is a surgically implanted titanium device designed to facilitate cannulation of uncannulatable dialysis access arteriovenous fistulas (AVFs) because of excessive depth, aneurysm formation, or tortuosity but that exhibit sufficient flow volume to support hemodialysis. We report the 18-month fistula patency, functionality, and complications of the use of the VWING device. This retrospective study examined AVF patency, VWING functionality, interventions, and device infections at 18months after VWING implantation. The study population comprised the eligible patients enrolled in the VWING Salvage of AV Fistula (SAVE) trial. Fifty-four patients were originally enrolled in the SAVE trial, and 35 were enrolled in the follow-up study. At18months, when considering surgical or percutaneous interventions at the VWING site(s) only, the primary AVF patency rate was 78%. Interventions elsewhere on the AVF, outside the boundaries of the VWING, resulted in a primary patency rate of 38%. The VWING accounted for 13% loss of AVF primary patency compared with 53% loss from the remaining AVFs. The overall AVF assisted primary patency rate was 91%, and the primary patency rate was 21%. VWING secondary functionality, the continued ability to access the fistula through the VWING using a constant site cannulation technique, was 65%. During the 12months after the SAVE Study 80% of patients did not require the use of a central venous catheter. Eleven VWING devices were removed from eight patients, all but one for cannulation difficulties. One device was removed during the SAVE trial because of infection. No device or systemic infection was identified in the ensuing 12months, for an overall systemic infection rate of 0.014 per device-year. An intervention rate of 0.32 per device-year was required to maintain device functionality during the 18-month follow-up period. Implantation of the VWING device is a safe and effective means of establishing hemodialysis access in an otherwise functional but uncannulatable AVF. The device infection rate is acceptably low.

Timing of first arteriovenous fistula cannulation in children on hemodialysis.

Due to lower complication rates in comparison to central venous catheter (CVC) arteriovenous fistulas (AVFs) are now the preferred hemodialysis access. Recommendations for the first access cannulation range from 6 to 12weeks, which could lead to temporary or even permanent preference for CVC while awaiting the maturation of the newly created AVF. The aim of this study was to evaluate the influence of first cannulation of AVFs on primary (PP) and secondary (SP) patency rates in children on hemodialysis (HD). This was a retrospective cohort study of 42 pediatric patients with a median age of 14 (range 7-17) years. At the time of surgical AVF creation 21 patients (end-stage renal disease) were still on HD via CVC or peritoneal catheter, while 21 were pre-emptive with initiation of HD expected within a few weeks. All patients received an AVF by the same experienced surgeon between February 1993 and May 2014. Primary failure (PF) was defined as the inability to use the AVF even once due to absent maturation or occlusion within 4weeks after creation. PP was defined as the interval from time of access placement to any intervention designed to maintain or reestablish patency, to access thrombosis or the time of measurement of patency, while SP was defined as the total lifespan from creation to access abandonment, end of follow-up or loss. Primary failure was observed in six (14.3%) of 42 AVFs (all radiocephalic fistulas) within the first 10days after cannulation. Excluding PF, the PP/SP rates at 1, 3, 6, 12, 18 and 24months were 100/100, 91/99, 86/98, 76/95, 55/85 and 44/77%, respectively. There was a significant decrease in PP when first cannulation was performed within the first 30days after creation compared to first cannulation performed after 30days (p = 0.004). In terms of PP/SP outcome and timing of the first cannulation, there was no significant difference in thee outcome of PP/SP between first cannulation within the first 45days after creation and that after 45days (p = 0.091/0.883). The findings suggest that cannulation of AVF within 30days after surgical creation reduces PP, while SP may be influenced less by time until cannulation. We also found no significant differences in PP after maturing periods of >45days.

Con: Buttonhole cannulation of arteriovenous fistulae.

Successful cannulation of arteriovenous fistulas (AVFs) using a safe and effective technique that minimizes patient harm is a crucial aspect of haemodialysis treatment. Although the current standard of care for many years has been the rope-ladder technique (using sharp needles to cannulate rotating sites across the entire AVF), a number of enthusiasts have recently advocated for the alternative method of buttonhole cannulation (using blunt needles to repeatedly cannulate the same site via a healed track) on the basis of putative, as yet unproven benefits. In this article, we review all available observational studies, randomized controlled trials, and systematic reviews and meta-analyses that have compared the clinical outcomes of buttonhole and rope-ladder cannulation of AVFs. These studies clearly and consistently demonstrated that buttonhole cannulation causes significant and serious infectious harm to haemodialysis patients, especially in the home setting. No strategies or treatments have been proven to effectively mitigate this hazard of buttonhole cannulation. Moreover, buttonhole cannulation is associated with a higher rate of abandonment and has not been shown to have any proven benefit compared with the rope-ladder method. Specifically, buttonhole cannulation has not been shown to reduce cannulation-related pain, improve vascular access survival, reduce vascular access interventions, reduce haematoma formation, improve haemostasis or reduce aneurysm formation. Consequently, rope-ladder cannulation should remain the standard of care and buttonhole cannulation should only be used in rare circumstances (e.g. short segment AVFs where the only alternative is a haemodialysis catheter).

Ultrasound-guided cannulation of hemodialysis access

Because hemodialysis therapy cannot be performed without the cannulation of a vascular access, establishing a well-functioning vascular access is crucial. Recently, the number of patients with difficult arteriovenous (AV) fistula cannulation has increased due to changes in the epidemiology of the dialysis population. To address this issue, indications for real-time ultrasound-guided techniques have recently been reported. This review discusses methods of ultrasound-guided cannulation of dialysis access; it is difficult to cannulate a deep, small, or stiff vessel of an AV fistula on the first attempt with static ultrasound guidance in which the ultrasound probe remains stationary. Mastering a method in which the precise location of the needle tip can be continuously identified during the insertion by dynamic probe scanning is required. To achieve this, understanding the theory of ultrasound guidance, off/on-the-job training, and a sense of professionalism are important. The use of ultrasound also enables the safe catheter placement into a collapsed central vein and repeated direct puncture of a femoral vein. The latter reduces the risk of catheter-related blood stream infection by avoiding the use of an indwelling dual-lumen catheter. In conclusion, ultrasound-guided techniques enable precise vascular cannulation, which can result in significant patient and financial impact. The accumulation of further reports is required for the method to be acknowledged as the standard to cope with difficult vascular access for dialysis. As most of the latest ultrasound machines for procedural guidance are optimized for peripheral nerve block, a compact and affordable ultrasound device with image quality focused on vascular access is also needed.

Improving vascular access outcomes: attributes of arteriovenous fistula cannulation success.

BackgroundArteriovenous fistulas (AVFs) are the preferred access for hemodialysis (HD) yet they are underutilized. Cannulation of the fistula is a procedure requiring significant skill development and refinement and if not done well can have negative consequences for patients. The nurses' approach, attitude and skill with cannulation impacts greatly on the patient experience. Complications from miscannulation or an inability to needle fistulas can result in the increased use of central venous catheters. Some nurses remain in a state of a ‘perpetual novice’ resulting in a viscous cycle of negative patient consequences (bruising, pain), further influencing patients' decisions not to pursue a fistula or abandon cannulation.MethodThis qualitative study used organizational development theory (appreciative inquiry) and research method to determine what attributes/activities contribute to successful cannulation. This can be applied to interventions to promote change and skill development in staff members who have not advanced their proficiency. Eighteen HD nurses who self-identified with performing successful cannulation participated in audio-recorded interviews. The recordings were transcribed verbatim. The data were analyzed using content analysis.ResultsFour common themes, including patient-centered care, teamwork, opportunity and skill and nurse self-awareness, represented successful fistula cannulation. Successful cannulation is more than a learned technique to correctly insert a needle, but rather represents contextual influences and interplay between the practice environment and personal attributes.ConclusionsPractice changes based on these results may improve cannulation, decrease complications and result in better outcomes for patients. Efforts to nurture positive patient experiences around cannulation may influence patient decision-making regarding fistula use.