Case Scenario 2 Part A

A 73 year old man is being conveyed from his own home in a blue light ambulance. He has end-stage renal disease of unknown aetiology and receives haemodialysis 3 times weekly. He had an uneventful dialysis session this morning but since returning home his fistula has started to bleed. The paramedics have applied a bandage and pressure but the bleeding appears to have continued unabated. You have 5 minutes to prepare yourself before the patient arrives. The following preparatory steps should be taken:

1. plan to receive the patient in the resuscitation room if at all possible
2. ensure you have enough pairs of hands – you will need a nurse and a second pair of hands as a minimum
3. this may well get messy – make sure everyone is wearing appropriate PPE (eye and face protection, apron, gloves etc.)
4. consider giving the renal and vascular team the heads up

Golden rules when dealing with grafts and fistula:

1. As a general rule, try not to touch a renal patient’s access site unless the patient is in extremis – do not take blood from them and do not administer drugs or fluids via them
2. Do not use a blood pressure cuff or tourniquet on the same arm as the graft/ fistula – you risk clotting the access

Always remember that a dialysis patients access site is their lifeline – it is a complete disaster for them to lose their access.

If a patient is in extremis and you are considering using their fistula to gain circulatory access, please consider the following:

1. Is there really no alternative? (What about ultrasound guided peripheral access or an intraosseous line?)
2. Do not use a tourniquet
3. Clean the site really, really well
4. Avoid puncturing the back wall of the vessel
5. Secure the IV catheter in VERY carefully
6. Remember you are dealing with a high pressure system – you will need a pressure bag in order to get fluid into the patient
7. Document the presence of a thrill before and after the procedure
8. 10-15 minutes of firm pressure will be required on removal of the catheter

Other access related problems:

1. Infection – inevitably there is a high risk of infection. Renal patients are relatively immunocompromised and the access site is constantly being needled. In the presence of an access infection, the patient may or may not have redness around the access site. There may or may not be pus. There needs to be an extremely high index of suspicion and remember that line/ access site infections can seed causing more unusual infections such as endocarditis, osteomyelitis and discitis.

2. Thrombosis – the patient will present with loss of a thrill or bruit from their graft or fistula. This is a clinical diagnosis but can be confirmed with ultrasound Doppler. Feel the fistula/ graft and then listen with a stethoscope or hand-held doppler (continuous flow should be heard). A high-pitched bruit may indicate imminent stenosis. As indicated above, this is more likely to occur in a graft than a fistula. There is usually 24-48 hours in which to de-clot the access site. This is often done by the interventional radiologists. From an ED perspective, make the diagnosis and refer the patient early.

Learning bite

In cases of access failure, it is important to check U&Es as the renal team will need to plan when (and how) the patient will next dialyse.