Feature

Vascular Access Emergencies in the Dialysis Patient

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

References

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Tranexamic Acid

Tranexamic acid is an antifibrinolytic agent that binds to fibrinogen as a competitive inhibitor of plasmin, inhibiting plasminogen activation. The trauma literature has shown TXA to significantly reduce all-cause mortality. ³⁶ It has also been shown to be beneficial in the bleeding uremic patient. ^37-39

However, it is important to keep in mind that the clearance of TXA in patients with renal disease is unclear. One study by Andersson et al ⁴⁰ demonstrated that TXA has increased plasma concentrations in patients with renal impairment, and a generally accepted practice is to renal-dose this medication. This study recommended a dose of 10 mg/kg IV at varying intervals, such as once daily, twice daily, or every 48 hours depending on the creatinine value, compared to patients with no renal impairment. ⁴⁰Another study by Sabovic et al ³⁹ that evaluated the effects of TXA on gastrointestinal bleeding in patients with renal impairment used a 20-mg IV loading dose of TXA followed by 10 mg/kg orally every 48 hours. Though no adverse events occurred in this study, the study group was small. Other studies have not shown an increase in thromboembolic risk in patients who have no renal disease. ^36,41

At this time, there is no consensus on the exact dosing of TXA in this patient population. Therefore, this therapy should only be considered if others have failed and the patient continues to have significant blood loss.

Life-threatening Hemorrhage

If a patient is experiencing life-threatening blood loss, more aggressive measures must be employed regardless of risk of damage to the access. In such cases, a consultation with vascular surgery services should be obtained as early as possible. If none of the previously discussed measures are ineffective, the EP may be required to place sutures in the vascular access itself or apply a tourniquet. Again, these interventions may cause permanent damage to the access; however, in the setting of life-threatening hemorrhage such interventions clearly outweigh the risks associated with continued blood loss.

As blood can flow bidirectionally within a fistula, a tourniquet should be placed both proximally and distally to the fistula to obtain adequate hemostasis. Once the tourniquets are in place, if there is no immediate surgical consultation available, the EP may need to temporarily repair the defect to allow minimal tourniquet time. There are a few considerations when placing sutures. Ideally, a noncutting needle should be used to minimize damage. An adequate-sized suture, such as a 3-0 nylon suture, should be used to maintain strength in the high-pressure system. A figure-8 suture or purse-string suture may be placed around the defect. Adequate repair should allow for tourniquet removal.

Hemodynamic Status

The EP must remain aware of the patient’s hemodynamic status. Massive transfusion protocols may need to be initiated. Best current evidence dictates that this should be done in a 1:1:1 ratio of packed red blood cells, platelets, and fresh frozen plasma respectively. ⁴² In our experience, the EP should consider permissive hypotension as aggressive resuscitation and increasing BP can compromise the vascular repair.