Point-of-care ultrasound-guided cannulation versus standard cannulation in hemodialysis vascular access: A controlled random order crossover pilot feasibility study

Abstract

Background: Standard cannulation practice for hemodialysis consists of inserting needles “blindly” through skin into an arteriovenous fistula (AVF), which is more likely to cause damage. Point-of-care ultrasound (POCUS) guided cannulation has potential for less damage; however, efficacy of this technique has not been explored. Our purpose was to test the feasibility and effectiveness of POCUS guidance for cannulation of AVFs in hemodialysis patients. Methods: A random-order crossover research design was used; patients and nurses acted as their own control. Sample included 13 patients with functioning AVFs and 9 nurses, recruited from a single hemodialysis center. All nurses cannulated all patients using standard and POCUS-guided cannulation. Data were collected at each cannulation (time taken, nurse position, probe direction, pressures, patient satisfaction, pain scores). Ultrasound images of needle position were collected from which needle tip locations inside vessels were measured. Nurses were surveyed at three timepoints and were interviewed at conclusion of data collection. Analysis involved linear mixed-models for clinical data, descriptive statistics for binary and feasibility data, and content analysis for interview data. Results: Eleven patients and seven nurses completed. Protocol adherence was 94.4%. Two miscannulations occurred, both during standard cannulation. Cannulation time using POCUS guidance was significantly higher than standard cannulation ( p = 0.008, 95% CI 39–166). All other variables showed no statistically significant difference. Content analysis of interview data showed cultural shift toward use of POCUS; nurses gained confidence and become more proficient in their POCUS technique. Conclusions: Random-order crossover is a feasible design to measure differences in POCUS-guided and standard cannulation. It is also feasible to implement POCUS into hemodialysis centers and whilst POCUS guidance takes longer, nurses become more proficient, and confident with persistent use.