1. Innovation and excellence in health and care Addenbrooke’s Hospital I Rosie Hospital Tattoo of Vascular Cannulation Site as a Self- Cannulation Aid Lagaac, R., Quian N., Meruz, R., Pritchard, N. and Go, A. Regin Lagaac Senior Clinical Nurse Specialist Vascular Access Cambridge University Hospitals United Kingdom

2. Innovation and excellence in health and care Introduction Haemodialysis The benefits of HHD: report a better quality of life travel time is eliminated and there is flexibility in scheduling the frequency and duration of dialysis sessions. The home setting presents a challenge.

3. SELF CANNULATION Self-cannulation has advantages as individuals who self- cannulate are able to feel the needle within their vessel during cannulation, so they are able to identify developing problems (Verhallen 2013). We describe a novel solution for patients who have difficulty in palpating their AVF, potentially allowing greater rates of self-cannulation. To our knowledge, no other institution has used tattoo markings in this way to delineate the appropriate cannulation path. Innovation and excellence in health and care

4. BACKGROUND A patient, with Body Mass Index (BMI) of 36, had a left radiocephalic AVF formed in January 2014. The fistula was difficult to palpate, as it was positioned more than 5mm below the skin. He initially dialysed at our centre, and was cannulated by the staff. He expressed a desire to dialyse at home, and was ‘trained to self- cannulate by the home therapies team. Home haemodialysis was initiated and he dialysed four times per week.

5. Innovation and excellence in health and care BACKGROUND Had difficulties palpating the fistula Occasionally deviate from the prescribed direction of cannulation. Despite this, he was still keen to continue home dialysis and had multiple sessions with the home therapies team for further education and confidence-building. MANAGEMENT We proposed marking the fistula margins with tattoo ink to help guide his cannulations. We referred him to the radiotherapy department at our hospital for tattoo placement. This was performed by the radiotherapy technicians.

6. CONSENT PROCESS The patient understood that the purpose of marking the skin was to help delineate the cannulation path. We explained that during the tattoo process, permanent ink marks that were made on the skin would remain even if the fistula were to fail. We also explained that a minority of people exhibit sensitivity to tattoo dyes, particularly red, green or white dyes, which could manifest as a localised skin rash. There were also slight risks of skin infection and scarring. Innovation and excellence in health and care

7. PROCEDURE The surface of the skin was cleaned with an alcohol swab. No local anaesthetic was applied. Ultrasound the AVF and identify the size and direction of the vein. The borders of the fistula vein were marked with a permanent marker. Innovation and excellence in health and care

8. PROCEDURE Tattoo ink was placed on the skin, and the epidermis was pricked with a 15G hypodermic needle to a depth of 1–2 mm. A series of discrete dots were placed to mark the borders of the fistula. This was completed in a matter of minutes with no complications. The site was dressed and he was advised to keep the site clean to minimise the risk of skin infection. Innovation and excellence in health and care

9. OUTCOME The tattoo served as a visual indication of the cannulation path. Innovation and excellence in health and care

10. DISCUSSION Tattooing of a patient’s vascular cannulation site is a useful option Enabled our patient to cannulate his fistula with confidence Tattoo ink is available in a variety of colours, and our radiotherapy department is trialling fluorescent tattoo ink which would only be visible under ultraviolet light. This may prevent any negative feelings about body image or the social stigma associated with tattoos. Whilst the buttonhole technique would also serve the same purpose, patients who are less skilled in cannulation may risk creating false tracts. A tattoo marking would give a visual indication of the direction but not the appropriate depth of cannulation, therefore tattooing would not be appropriate for patients with very mobile vessels. Innovation and excellence in health and care

11. IMPLICATION FOR PRACTICE This solution could potentially be used when a fistula is difficult to palpate. A tattoo could also be used in rural or satellite dialysis units where ultrasound is not readily available. Due to its visibility and permanent nature, patients have to be counselled appropriately. The expected lifespan of the fistula should also be considered before utilisation of this technique. Innovation and excellence in health and care