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Vascular Access Emergencies in the Dialysis Patient

Emergency Medicine. 2017 September;49(9):392-404 | 10.12788/emed.2017.0055
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Table.

The Table provides a summary of the general approach to patient hemorrhaging from a vascular access.

Peripheral Venous Access

While peripheral venous access is notoriously difficult in patients with ESRD, it is essential for the resuscitation of hemorrhaging patients. Ideally, two large bore peripheral intravenous (IV) lines should be placed in the proximal upper extremities. If peripheral venous access is not achieved, central venous access or interosseous access placement is indicated ( Figure).

Figure.

In the rare case of a dialysis patient requiring immediate access, and there are no other options available, the functioning fistula or graft may be accessed. This technique is similar to placing a peripheral IV line, and a tourniquet should be applied to the axilla. Aseptic technique should be used prior to inserting a large bore needle (ie, 16 to 18 gauges) at an approximately 20- to 35-degree angle for AVFs, and 45-degree angle for AFGs. Once flash is obtained, the provider should advance the needle approximately one-eighth of an inch more before dropping the angle flush with the skin. 20 The catheter should then be advanced to the hub and secured extremely and closely observed while in place given the high pressures in a vascular access. It is important to be mindful of the fact that all vascular access, both AVF and AVG, are high-flow sites; therefore, fluids and blood products may need to be pressurized to ensure adequate infusion. This should be performed as a temporizing measure while obtaining alternative access.

Direct Pressure

With low-volume bleeding, the first attempt to control the bleeding is simple direct pressure. Except in the instance of trauma or self-inflicted injury, bleeding usually occurs at the site of cannulation of the vascular access post-HD. Direct pressure should be light and limited to as small of an area as possible to prevent thrombosis; the force and area encompassed by direct pressure can be expanded as needed for bleeding that is more difficult to control. In cases of higher volume bleeding, pressure should be placed both proximally and distally to the shunt due to its bidirectional flow. Another possible temporizing measure is to place an upright gallipot or cup over the bleeding site on top of a folded piece of gauze and then securing it with tape. 21

Topical Hemostatic Agents

Second simple direct pressure, topical hemostatic agents may be a good adjunct to help obtain hemostasis. There is a wide range of products available, from procoagulants (eg, Combat Gauze, topical thrombin) to factor concentrators (eg, QuikClot). These can be used directly on the bleeding site and only in conjunction with direct pressure.

In addition to topical hemostatic agents, another option is skin glue, which should be applied generously after bleeding has been temporized, with pressure both proximally and distally to the site.

Anticoagulation Reversal

As previously mentioned, it is important to determine when the patient’s last HD was. Heparin is used during dialysis to prevent clotting within the circuit, and although clotting times are monitored during dialysis to guide anticoagulation, it is possible that a patient bleeding after dialysis could still have therapeutic levels of heparin requiring reversal with protamine.

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