– Emergency Medication EducationThe Dialysis Affected person: Managing Fistula Issues within the Emergency Division –

emDOCs.net – Emergency Medicine EducationThe Dialysis Patient: Managing Fistula Complications in the Emergency Department - emDOCs.net
September 18, 2016 0 Comments

Writer: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident at SAUSHEC, USAF) // Edited by: Jennifer Robertson, MD, MSEd and Alex Koyfman, MD (@EMHighAK, EM Attending Doctor, UTSW Medical Middle / Parkland Memorial Hospital)

A 78-year-old male with a previous medical historical past of coronary artery illness, hypertension and finish stage renal illness presents to the emergency division (ED) with a chief criticism of “can’t cease bleeding.”  The affected person is seated in triage, holding a blood-soaked towel over his left arm.  As you method him, you scan his consumption sheet and notice the next VS: Blood strain (BP) 72/59, coronary heart price (HR) 127 beats per minute, respiratory price 18/minute, temperature (T) 102.1°Fahrenheit (F).  As you raise the towel, a big quantity of blood pours from his hemodialysis fistula.  You instruct the affected person to proceed holding agency strain and take into account attainable etiologies of the bleeding.

You acknowledge that the affected person is hemodynamically unstable, wants blood and an infectious workup, however what’s the subsequent step if direct strain is unsuccessful?

The next assessment features a few suggestions and tips for figuring out and treating widespread hemodialysis (HD) issues.

Epidemiology of Power Kidney Illness

In the USA, roughly 300,000-400,000 continual kidney illness sufferers are maintained on HD.1-4  The method of HD requires vascular entry by way of an arteriovenous (AV) fistula, AV graft, or central venous catheter (CVC).  Immediately, because of the Nationwide Kidney Basis’s “Fistula First” initiative, almost 55% of HD sufferers make the most of an AV fistula.  .4,5  Important morbidity and mortality are related to fistula placement and recurrent cannulation. Due to the potential of issues involving fistulas, EM physicians ought to acknowledge and deal with vascular insufficiency, hemorrhage, an infection, stenosis, thrombosis, aneurysms, and pseudoaneurysms.

Vascular Insufficiency – Dialysis Related Steal Syndrome (DASS)

DASS is a complication of AV fistulas and its incidence is reported as excessive as 8% within the present vascular literature.3  DASS happens secondary to retrograde circulation from the artery distal to the AV anastomosis, and is seen mostly when a big artery (brachial or superficial femoral) provides blood by way of the fistula into a big, low-pressure vein.6,7  Signs of DASS progress from a painless cool extremity, to claudication, relaxation ache, and at last to tissue necrosis.6  Whereas the vast majority of sufferers with symptomatic DASS current inside one month of AV fistula creation, there are some reviews detailing circumstances as late as one yr put up process.7

 Examination of a affected person with DASS contains the pathognomonic discovering of a diminished or absent distal radial pulse, palpable solely with compression of the dialysis entry website.6  Though formal ultrasound (US) might reveal high-velocity, retrograde circulation by way of the HD fistula, this isn’t a delicate indicator of DASS because the prognosis is predicated on scientific signs.6,7  The gold customary in addressing DASS is ligation of the AV entry; due to this fact, vascular surgical session is required urgently or emergently in keeping with symptom severity.7


Within the HD affected person, hemorrhage typically arises secondary to platelet dysfunction (uremia or transient thrombocytopenia noticed within the ESRD inhabitants), supra-therapeutic anticoagulation, or fistula abnormalities (an infection, stenosis, aneurysms, pseudoaneurysms).1,6,8

 Mechanisms for Acquiring Hemostasis

Direct Stress

Direct strain is the first intervention for controlling hemorrhage.  It must be utilized to the positioning of bleeding for 5-10 minutes.1,5,7,8  If hemostasis is achieved, sufferers must be noticed for 1-2 hours to observe for recurrent bleeding.1,6,8

Word: Nearly all of hemodialysis literature advises in opposition to the applying of extreme strain as it could result in iatrogenic fistula thrombosis.5,7 How a lot strain is an excessive amount of strain?  That is tough to find out.

Topical Hemostatic Brokers

Gelfoam – Whereas there aren’t any trials or research particularly assessing the utilization of gelfoam within the setting of vascular entry hemorrhage, its use is extensively detailed in emergency medication literature.1,9,10   Gelfoam is a water-insoluble sponge ready from purified porcine pores and skin, gelatin granules, and water, which when utilized to a bleeding website acts as a mechanical matrix facilitating clot formation.11  Gelfoam could also be saturated with sterile saline previous to software or utilized on to the bleeding website till hemostasis is achieved.1,9  As soon as hemostasis has been attained, a bandage could also be utilized over the gelfoam (taking precautions to keep away from extreme strain which, as above, predisposes the affected person to iatrogenic thrombosis).1

 Chitosan – Obtainable as HemCon®, chitosan is a non-toxic, advanced carbohydrate derived from chitin. It’s identified to exhibit a mucoadhesive exercise when utilized on to an damage website with lively blood extravasation.12  One randomized management trial of fifty HD sufferers with vascular hemorrhage demonstrated improved time to hemostasis on the 4 minute remedy level after the applying of HemCon® beneath direct strain versus the applying of direct strain with plain gauze.13

Thrombin – Recombinant human thrombin (rhThrombin) was authorised by the FDA in 2008. It helps attain hemostasis at any time when management of bleeding by suture, ligature, or cautery is ineffective or impractical.14  Thrombin performs a vital position within the intrinsic and extrinsic pathways of the coagulation cascade, activating elements XI, VIII, V, XII, and I (fibrinogen), thereby facilitating hemostasis.10  Recombinant human thrombin could also be utilized together with a gel foam product.1,14  The commonest adversarial response to rhThrombin is thrombosis, nonetheless, thrombosis occurring secondary to topical software within the setting of fistula hemorrhage has not been evaluated.14  (Thrombosis has been famous to happen in 1% of grownup and pediatric burn sufferers (N=72) after software to acquire hemostasis at graft websites).14

Reversal of Supra-Therapeutic Anticoagulation – Heparin is often utilized in dialysis facilities. Persistent oozing or bleeding occurring inside hours of HD ought to elevate concern for over anticoagulation.  Specialists suggest the usage of intravenous protamine at a dose of 1 mg for each 100mg heparin given throughout dialysis. If the dose of heparin is unknown, 10-20 mg of protamine must be given in complete (estimated enough to reverse a median dose of 1,000-2,000 models of heparin).1,7

Pharmacotherapy – Desmopressin (DDAVP) is an artificial analogue of anti-diuretic hormone (ADH). It’s FDA authorised for the remedy of bleeding episodes in sufferers with Hemophilia A and von Willebrand’s illness (Sort 1).1,9,10   Whereas the mechanism of motion has but to be elucidated, DDAVP has been demonstrated to lower the activated partial thromboplastin and bleeding instances in uremic sufferers,15 in addition to to stop bleeding previous to invasive procedures in HD sufferers.1,16,17  This compound could also be utilized by the emergency doctor (in session with a vascular surgeon) to handle hemorrhage from AV grafts or fistulae.1,16  DDAVP must be given parenterally with a really helpful dose of 0.3mcg/kg over ten minutes. It’s contraindicated in sufferers with a historical past of hyponatremia, unstable angina, or congestive coronary heart failure.1,14

 If the above interventions have failed to achieve hemostasis, vascular surgical procedure must be consulted instantly for intervention.1,7,9  If ED intervention is required to stop dying, a tourniquet or sturdy handbook strain could also be utilized to the fistula website.1,9  Fistula thrombosis and lack of limb might happen on this situation.1,7,9

 An infection

Vascular entry an infection is a serious reason behind morbidity and mortality in HD sufferers.6,18  Present knowledge estimate the speed of AV fistula an infection as between 2-5%.10  Given the altered humoral and cell-mediated immunity occurring in chronically uremic HD sufferers, people with an AV fistula an infection might lack localized inflammatory findings (rubor, calor, dolor) and current solely with intermittent fever, generalized malaise, minimally elevated white blood cell rely, and/or hypotension.6   The commonest infecting organism within the HD inhabitants is Staphylococcus aureus, adopted by Staphylococcus epidermidis and gram-negative micro organism.6,19

Suspected fistula infections must be managed aggressively with blood cultures and intravenous antibiotics.  Beneficial antibiotic remedy contains vancomycin (15mg/kg or 1g IV). Gentamicin (100mg IV initially and after every dialysis remedy) must be given if an an infection with gram-negative organisms is suspected.6,19   Sufferers must be hospitalized till cultures are resulted and susceptibilities are identified in order that antibiotic remedy may be narrowed (lowering the incidence of vancomycin-resistant organisms).20

Ultrasound must be utilized to distinguish fistula an infection from contaminated thrombus, native abscess, or contaminated hematoma which require vascular surgical procedure session and oftentimes surgical administration.20

 Fistula Stenosis

Stenosis and thrombosis are the commonest issues of AV fistulas.21  Central vein stenosis happens in 19-41% of HD sufferers.22  Sufferers presenting to the ED with fistula stenosis might report misery secondary to higher extremity and chest wall edema.  Bodily examination is important within the emergency doctor’s analysis of stenosis and it’ll differ in keeping with the stenosed section (influx versus outflow stenosis).23  Influx stenosis presents with a weakened radial pulse and a excessive pitched bruit within the systolic part of the cardiac cycle on the website of stenosis.23    In distinction, outflow stenosis is recognized as the positioning distal to the stenosis reveals a bounding pulse and absent thrill.  Within the ED, Doppler US could also be utilized for the evaluation of vascular circulation.  Vascular surgical procedure must be consulted for sufferers presenting to the emergency division with the aforementioned symptomatology, as percutaneous transluminal angioplasty is the remedy of selection.23

Fistula Thrombosis

Thrombosis is a standard downside related to vascular entry.10  AV fistula thrombosis is prone to happen secondary to venous outflow stenosis (venous stenosis will increase resistance to blood circulation, which in flip ends in elevated venous strain, decreased blood circulation, and finally, thrombosis1). Fistula thrombosis can even happen in hours following dialysis remedy as sufferers are sometimes comparatively hypovolemic (venous stasis) and the fistula entry website could also be excessively compressed to achieve hemostasis.1,8  Erythropoietin remedy, typically prescribed to handle the continual anemia encountered in ESRD sufferers,  has been famous to extend the danger of thrombotic issues secondary to elevated ranges of acute part reactant proteins and continual irritation.7

AV fistula thrombosis is shortly recognized by inspecting the fistula website for the absence of a bruit and thrill.1,7,8  Within the case of thrombosis, vascular surgical procedure must be consulted instantly.  Administration choices embrace surgical thrombectomy versus thrombolysis with streptokinase or tissue plasminogen activator with or with out angioplasty.1,8,24

 Fistula Aneurysm or Pseudoaneurysm

Aneurysms type in AV fistulas secondary to repetitive cannulation and subsequent weakening of vessels partitions.8,10  Sufferers with aneurysms might current to the emergency division reporting extremity ache, neurologic dysfunction secondary to aneurysmal impingement of surrounding nerves, vital thinning of overlying fistula pores and skin, or hemorrhage secondary to this pores and skin erosion.8,25

 Pseudoaneurysms are pulsating extravascular hematomas ensuing from dialysis website entry. These are uncommon issues  of AV fistula entry.7,10  As in comparison with aneurysms, sufferers with pseudoaneurysms usually tend to current to the emergency division for vascular hemorrhage or indicators and signs per an infection.7,10,25  Each AV fistula aneurysm and pseudoaneurysms may be recognized with the usage of Doppler US.7  Vascular surgical procedure must be consulted for all detected vessel irregularities for consideration for operative restore.7,10


Practically 400,000 people in the USA are maintained on HD remedy.1-4  With incident circumstances of ESRD reaching almost 21,000 yearly, and vascular entry issues accounting for 16 to 25% of hospital admissions,5,7 understanding of the suitable administration of AV fistula issues is paramount for the emergency medication doctor.

 Key Pearls

  • Fistula issues = 16-25% of hospital admissions for HD sufferers
    • DASS => complication of operative creation of a HD fistula
      • Prognosis based mostly upon presentation and PE
        • Cool/painful limb + diminished or absent distal radial pulse, palpable solely with compression of the dialysis entry website => Vascular Seek the advice of
      • Hemorrhage
        • #1 = direct strain
        • Gel foam, rhThrombin +/- DDAVP in session with a specialist are choices
        • Take into account protamine for heparin reversal if just lately acquired dialysis
      • An infection
        • Frequent reason behind morbidity = cowl for Staph and Strep
        • Use US to distinguish perivascular cellulitis from native abscess, contaminated hematoma or contaminated thrombus.
          • Perivascular cellulitis => Vancomycin (+ gentamycin if gram negatives suspected)
          • Abscess, hematoma, thrombus => Antibiotics + vascular seek the advice of for attainable OR
        • Fistula Stenosis
          • Sufferers current with extremity ache +/- chest wall edema
            • Order Doppler US
              • Abnormalities = seek the advice of vascular => PTCA
            • Fistula Thrombosis
              • Fistula has absent bruit or thrill = vascular seek the advice of => thrombectomy vs. thrombolysis
            • Fistula Aneurysm or Pseudoaneurysm
              • Sufferers current with extremity ache, compression neuropathy, or hemorrhage secondary to pores and skin erosion.
                • Doppler US => vascular seek the advice of for abnormalities

References / Additional Studying

  1. Larsen C, Weathers B, Schwartzwald M, Barton M. Give attention to: dialysis entry emergencies. American School of Emergency Physicians Scientific & Follow Administration 2010. Obtainable from https://www.acep.org/Scientific—Follow-Administration/Focus-On–Dialysis-Entry-Emergencies/
  2. Soi V, Moore C, Kumar L, Yee J. Prevention of catheter-related bloodstream infections in sufferers on hemodialysis: challenges and administration methods. Int J Nephrol Renovasc Dis. 2016;9:95-103.
  3. Leake A, Winger D, Leers S, Gupta N, and Dillavou E. Administration and outcomes of dialysis access-associated steal syndrome. J Vasc Surg. 2015; 61(3): 754-760.
  4. KDOQI Scientific Follow Tips and Scientific Follow Suggestions for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Entry. Am J Kidney Dis. 2004; 48:S1-S322.
  5. United States Renal Knowledge System (USRDS) Annual Knowledge Report. Epidemiology of kidney illness in the USA. 2015. Obtainable from: https://www.usrds.org/adr.aspx
  6. Dhingra R, Younger E, Hulbert-Shearon T, Leavey S, Port F. Sort of vascular entry and mortality in US hemodialysis sufferers. Kidney Int. 2001; 60(4):1443-1451.
  7. Hodde L, Sandroni S. Emergency division analysis and administration of dialysis affected person issues. J Emerg Med. 1992; 10:317-334
  8. Wolfson A, Singer I. Hemodialysis-related emergencies-part I. J Emerg Med. 1987; 5(6):533-543.
  9. Venkat, A. Difficult and Rising Circumstances in Emergency Medication. Chichester, West Sussex: Wiley-Blackwell, 2011. Print.
  10. Tintinalli, J. Tintinalli’s Emergency Medication: A Complete Research Information. New York: McGraw-Hill, 2011. Print.
  11. United States Meals and Drug Administration. Gelfoam (absorbable gelatin powder). Machine Approvals, Denials, and Clearances. 2000. Obtainable at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfTopic/pma/pma.cfm?num=n18286s012
  12. Wedmore I, McManus J, Pusateri A, Holcomb J. A particular report on the chitosan-based hemostatic dressing: expertise in present fight operations. J Trauma. 2006; 60(3):655-658.
  13. Bachtell N, Goodell T, Grunkemeier G, et al. Therapy of dialysis entry puncture wound bleeding with chitosan dressings. Dialysis Transplant. 2006:35:1-6.
  14. United States Meals and Drug Administration. Recothrom, thrombin topical (recombinant lyophilized powder for solution-for topical use solely. Highlights of prescribing Data. 2008. Obtainable from: http://www.fda.gov/downloads/Biologi…/ucm120557.pdf
  15. Mannucci P, Remuzzi G, Pusineri F, et al. Deamino-8-D-arginine vasopressin shortens the bleeding time in uremia. N. Engl. J. Med. 1983;308:8-12.
  16. Mannucci PM. Desmopressin (DDAVP) within the remedy of bleeding problems: the primary 20 years. Blood 1997;90:2515-21.
  17. Lethagen S. Desmopressin (DDAVP) and hemostasis. Ann. Hematol. 1994;69:173-80.
  18. U.S. Renal Knowledge System: Chapter 3: Hospitalizations. In: USRDS 2012 Annual Knowledge Report: Atlas of Power Kidney Illness and Finish-Stage Renal Illness in the USA, Nationwide Institutes of Well being. Bethesda, MD, Nationwide Institute of Diabetes and Digestive and Kidney Ailments, 2012
  19. Ball L. Deadly vascular entry hemorrhage: lowering the percentages. Nephrol Nurs J. 2013; 40(4):297-303.
  20. Hammes M. Medical issues in hemodialysis sufferers requiring vascular entry radiology procedures. Semin Intervent Radiol. 2004; 21(2):105-110.
  21. Pirozzi N, Garcia-Medina J, Hanoy M. Stenosis complicating vascular entry for hemodialysis: indications for remedy. J Vasc Entry. 2014; 15(2):76-82.
  22. Quaretti P, Galli F, Moramarco L, Corti R, Leati G, et al. Dialysis catheter associated superior vena cava syndrome with patent vena cava: long run efficacy of unilateral viatorr stent-graft avoiding catheter manipulation. Korean J Radiol. 2014; 15(3):364-269.
  23. Vachharajani, T. Prognosis of arteriovenous fistula dysfunction. Seminars in Dialysis. 2012; 25(4): 445-450.
  24. Bernal NP, Grammer ME, Mark JR, et al. Surgical thrombectomy stays a typical of take care of remedy of thrombosed arteriovenous grafts. J. Surg. Res. 2008;144:362-3.
  25. Siedlecki A, Barker J, Allon M. Aneurysm formation in arteriovenous grafts: associations and scientific significance. Seminars in Dialysis. 2007; 20(1):73-77.

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