Bleeding AV Access

Bleeding AV Access

Background

  • Most often occurs at dialysis center after fistula site is accessed
  • Presents as punctate bleed overlying fistula. Can be slow oozing bleed from uremia or high-pressure bleed similar to arterial bleed
    • Slow oozing bleed is less common in ED as hemostasis is often achieved at dialysis center
  • Ask the patient what type of AV access they have just in case you’re required to suture into the site
    • AV Fistula:  direct connection between the patient’s artery and nearby vein. Because it is the patient’s own tissue, it is less prone to clotting or infection. It takes 2-3 months for a fistula to mature. If it fails to mature, the procedure may be repeated
      • AV fistula.jpg
    • AV Graft:  indirect connection between artery and vein. Most commonly via a plastic tube, but also can be donated cadaver arteries or veins
      • AV Graft

How to Fix Most bleeds

  • First thing’s first, these patients are typically presenting from their dialysis clinic, therefore, someone already has held pressure and wrapped the site. If there is oozing or bleeding from around the dressing, then need to unwrap the site to visualize where the bleed is occurring from (recommend face shield, surgical gown)–nothing worse than starting your shift with an exposure visit
    • Bulky dressings allow for continued bleeding. Need to unwrap to see what you’re dealing with
  • Bleeding will often be from a small punctate site, therefore, once site of bleeding is visualized, then can apply firm pressure directly to this area to stop bleeding
    • This is a high pressure bleed so often will have to hold direct pressure for 10-20 minutes.
    • Taping gauze or wrapping in ACE bandage will often not be enough pressure to stop bleed, and will often prolong time to final hemostasis
  • Prior to holding pressure above, can spray topical TXA over bleeding site and place gelfoam (or surgicel) overlying punctate bleeding area
    • Gelfoam is a water-insoluble sponge prepared from purified porcine skin, gelatin granules, and water, which when applied to bleeding site acts as a mechanical matrix facilitating clot formation

If bleeding Continues…

  • If cannot control with above
    • Then have “helper” apply pressure proximal and distal to punctate bleed. This will reduce arterial and venous flow to the fistula, and stop bleeding. This will allow you to apply “topical meds” (e.g. TXA, Gelfoam).
      • see example of helper in “Real life example video” below
  • Figure of 8 Suture
    • If bleeding does not stop with above, then have “helper” apply pressure to proximal and distal areas again and apply figure of 8 suture
    • In the above video, they use 5-0 Prolene  (also found some literature where they used 3-0 nylon suture).
    • A lot of the sources state to use a non-cutting suture so that the graft or fistula is not further damaged with the suturing. I think this will be challenging in most EDs so this would be preferred but likely hard to find on the spot.

Cutting vs. Non-cutting needles

  • If the wound is larger than a punctate lesion, can also consider tying a purse string suture
Purse string.jpeg
Purse String Pattern

In severe bleeding, can also consider reversing coagulopathy…

  • Can consider IV TXA
  • Can consider protamine as often receive low dose heparin during hemodialysis
    • Found literature that suggested IV protamine at dose of 1 mg for every 100 mg heparin given during HD. Unlikely to know heparin dose so if unknown, then can give 10-20 mg of protamine (this is sufficient to reverse average dose of 1,000-2,000 units of heparin)
  • Can consider DDAVP for platelet-induced dysfunction from uremia (should likely discuss with vascular surgeon prior to giving)
    • DDAVP IV 0.3 mcg/kg over 10 minutes (contraindicated in pts with hyponatremia, unstable angina, or CHF)

Last resort

  • Can apply tourniquet, though, this puts pt at risk of fistula thrombosis

Dispo

  • Recommend 1-2 hours of observation for re-bleeding. Have them get up and move around. Don’t want them going home with bleeding starting at home
  • If bleed required suture or other advanced techniques, then should touch base with vascular surgery or IR (depending on who placed the fistula). At Rush, this consult is often for transplant surgery as they handle majority of our AV fistulas

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