We have point of care ultrasound in all of our facilities. They have limited use but I guess the nurses are learning to use them and over a period of time that may become a norm. It is helpful to use it in patients who have deep fistulas to know not to cannulate.

POCUS has successfully been utilized for cannulation mapping and real-time guided cannulation. Adoption within the USA has been very slow as pilots of the use were done years ago by the two largest LOD’s.
The key elements of a cannulation map include the target cannulation zones for both arterial and venous needles, vessel depth from the skin to the top of the vessel/graft (need to determine the needle entry angle) and vessel size (for needle gauge). The maps can be created and then available for staff when cannulating the access. The availability of the cannulation map chairside is a barrier to use.
The real-time cannulation takes more skill as it changes the normal hand position and movement when cannulating. It also increases the time for dialysis initiation and that can cause pushback with the current rapid workflows.
Some key references:
Schoch, M., Fielding, C., Marticorena, R. M., Smith, G. E., Sinclair, P. M., Iglesias, R., & Bennett, P. N. (2024). Barriers and facilitators to vascular access point-of-care ultrasound in haemodialysis: An international survey of haemodialysis clinicians. Journal of renal care, 10.1111/jorc.12503. Advance online publication. https://doi.org/10.1111/jorc.12503

Dua Niyyar, V., Buch, K., Rawls, F., & Broxton, R. (2023). Effectiveness of ultrasound-guided cannulation of AVF on infiltration rates: A single center quality improvement study. The journal of vascular access, 24(2), 322–328. https://doi.org/10.1177/11297298211034280

Chen, S., Liu, J. S., Chai, C. C., Si, C., Tan, S. H., Ravindran, H. R., Martinez, M. T. P., Gao, Y., Yeap, Y. R., & Liu, A. Y. L. (2023). Handheld ultrasound-guided cannulation of difficult hemodialysis arteriovenous access: A randomized controlled trial. Hemodialysis international. International Symposium on Home Hemodialysis, 27(1), 21–27. https://doi.org/10.1111/hdi.13050

Schoch, M., Bennett, P. N., Currey, J., & Hutchinson, A. M. (2020). Point-of-care ultrasound use for vascular access assessment and cannulation in hemodialysis: A scoping review. Seminars in dialysis, 33(5), 355–368. https://doi.org/10.1111/sdi.12909

Schoch M, Bennett PN, Currey J, Smith V, Orellana L, Hutchinson AM. Point-of-care ultrasound-guided cannulation versus standard cannulation in hemodialysis vascular access: A controlled random order crossover pilot feasibility study. The Journal of Vascular Access. 2023;24(5):1140-1149. doi:10.1177/11297298211069821

Eves, J., Cai, P., Latham, R., Leung, C., Carradice, D., Chetter, I., & Smith, G. (2021). A randomised clinical trial of ultrasound guided cannulation of difficult fistulae for dialysis access. The journal of vascular access, 22(4), 635–641. https://doi.org/10.1177/1129729820954725

Iglesias, R., Lodi, M., Rubiella, C., Teresa Parisotto, M., & Ibeas, J. (2021). Ultrasound guided cannulation of dialysis access. The journal of vascular access, 22(1_suppl), 106–112. https://doi.org/10.1177/11297298211047328

POCUS has successfully been utilized for cannulation mapping and real-time guided cannulation. Adoption within the USA has been very slow as pilots of the use were done years ago by the two largest LOD’s.
The key elements of a cannulation map include the target cannulation zones for both arterial and venous needles, vessel depth from the skin to the top of the vessel/graft (need to determine the needle entry angle) and vessel size (for needle gauge). The maps can be created and then available for staff when cannulating the access. The availability of the cannulation map chairside is a barrier to use.
The real-time cannulation takes more skill as it changes the normal hand position and movement when cannulating. It also increases the time for dialysis initiation and that can cause pushback with the current rapid workflows.
Some key references:
Schoch, M., Fielding, C., Marticorena, R. M., Smith, G. E., Sinclair, P. M., Iglesias, R., & Bennett, P. N. (2024). Barriers and facilitators to vascular access point-of-care ultrasound in haemodialysis: An international survey of haemodialysis clinicians. Journal of renal care, 10.1111/jorc.12503. Advance online publication. https://doi.org/10.1111/jorc.12503

Dua Niyyar, V., Buch, K., Rawls, F., & Broxton, R. (2023). Effectiveness of ultrasound-guided cannulation of AVF on infiltration rates: A single center quality improvement study. The journal of vascular access, 24(2), 322–328. https://doi.org/10.1177/11297298211034280

Chen, S., Liu, J. S., Chai, C. C., Si, C., Tan, S. H., Ravindran, H. R., Martinez, M. T. P., Gao, Y., Yeap, Y. R., & Liu, A. Y. L. (2023). Handheld ultrasound-guided cannulation of difficult hemodialysis arteriovenous access: A randomized controlled trial. Hemodialysis international. International Symposium on Home Hemodialysis, 27(1), 21–27. https://doi.org/10.1111/hdi.13050

Schoch, M., Bennett, P. N., Currey, J., & Hutchinson, A. M. (2020). Point-of-care ultrasound use for vascular access assessment and cannulation in hemodialysis: A scoping review. Seminars in dialysis, 33(5), 355–368. https://doi.org/10.1111/sdi.12909

Schoch M, Bennett PN, Currey J, Smith V, Orellana L, Hutchinson AM. Point-of-care ultrasound-guided cannulation versus standard cannulation in hemodialysis vascular access: A controlled random order crossover pilot feasibility study. The Journal of Vascular Access. 2023;24(5):1140-1149. doi:10.1177/11297298211069821

Eves, J., Cai, P., Latham, R., Leung, C., Carradice, D., Chetter, I., & Smith, G. (2021). A randomised clinical trial of ultrasound guided cannulation of difficult fistulae for dialysis access. The journal of vascular access, 22(4), 635–641. https://doi.org/10.1177/1129729820954725

Iglesias, R., Lodi, M., Rubiella, C., Teresa Parisotto, M., & Ibeas, J. (2021). Ultrasound guided cannulation of dialysis access. The journal of vascular access, 22(1_suppl), 106–112. https://doi.org/10.1177/11297298211047328

I provided ultrasound for our home dialysis and incenter units about 20 years ago. But training was only through my demonstrations, and use was mostly by the vascular access nurse and a few other nurses. There were no recommendations or procedures defined by the unit manager for how and when to use it. To make its value obvious, every nurse should be trained, and a limited but clear criterion for its use defined. I recommend that nurses should use the ultrasound to define the course, depth and size of the main fistula tract for each patient in which a new or revised fistula is being used. Use a magic marker to mark a line on the skin 1 inch outside the center of the fistula (draw it on both sides of the ultrasound probe as the center of the probe is moved along the center of the fistula). Sterile prep can then be used between the lines, so they will stay visible for a few treatments. Mark an X also for desired first sticks and describe depth of the fistula surface in the chart. With this management strategy, all the nurses will be familiar with the ultrasound and its value in a while, and needle insertions will be easier and shorter in duration. More importantly, risk of damage to the fistula will be less.

I have had more success with my inpatient nurses than on the outpatient side. On the inpatient side, we have an ultraportable with tablet that is available, I did sessions with all the nurses on how to cannulate a vein using blue phantoms and then demonstrated what it looks like on a patient, and now for those more difficult patients (deeper, fresh fistulas, prior infiltration) they will first try to identify if they can attempt by themselves with the ultrasound before escalating to the fellows and attendings, then the vascular team. This has been pretty successful since the nurses are aware of their own skills and take charge more than the techs and it is a limited pool of participants. So far so good!

Using the ultrasound for real time puncture of the fistula is valuable. But holding the probe in just the right position and with the same pressure on the skin is difficult while inserting the needle with the other hand, and the nurse can't stretch the fistula as many do commonly. I keep a laboratory ring stand in the unit and attach the probe to one of the clamps on the stand. It holds the probe while I wipe the skin around it, and insert the needle. It looks kind of medieval, but works very well.

I have had an ultrasound available for every patient encounter - in the office, in the OR, and selectively on hospital rounds - for the last 24 years, but absolutely no experience with ultrasound being used in the dialysis units. In the "good old days" one could think about training the "Access coordinator", NP or PA, or other nurse leaders, but these days it sounds as if the revolving door moves people in and out too quickly for anyone to acquire much understanding.
What I DID do was to provide the "Ultrasound assisted digital photo diagram" to each patient as I released their access for use - an 8 by 11 glossy photo picture of the patient's arm with the fistula drawn out on it. Sizes, depths, course, areas to avoid, recommended cannulation zones, etc. If the dialysis tech don't have an ultrasound to work with, or the training, at least they can have a reference to go by, and eliminate some of the guesswork.

i CAN ATTEST TO THE VALUE OF THE "Ultrasound assisted digital photo diagram" PROMOTED. . tHE STAFF AT HFHS FOUND IT QUITE VALUABLE

i CAN ATTEST TO THE VALUE OF THE "Ultrasound assisted digital photo diagram" PROMOTED. . tHE STAFF AT HFHS FOUND IT QUITE VALUABLE

I find the use of ultrasound essential in the evaluation of each patient, in the office, hospital rounds, and dialysis units, now my evaluations without it seem incomplete to me.