HWN Suggests

Bleeding AV Access

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.

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 Dialysis Access Emergencies

Vascular access complications are frequently encountered in the emergency department and often warrant an inpatient hospital stay. ESRD patients have coagulopathies that are associated with chronic renal failure or occurring because of repeated utilization of their access sites. A more stress-provoking situation is the potential severe hemorrhage that can occur at dialysis access sites.

 POTD: Dialysis Catheter Placement

Catheters placed through the IJ or subclavian optimal tip location is at the junction of the superior vena cava and right atrium roughly around 15cm in length is appropriate.

Articles of Interest

The Dialysis Patient: Managing Fistula Complications in the Emergency Department

In the HD patient, hemorrhage often arises secondary to platelet dysfunction (uremia or transient thrombocytopenia observed in the ESRD population), supra-therapeutic anticoagulation, or fistula abnormalities (infection, stenosis, aneurysms, pseudoaneurysms).

Vascular Access Emergencies in the Dialysis Patient

Control of a bleeding dialysis access-site is a balancing act of adequately controlling the bleeding while maintaining the integrity of the fistula. Overly aggressive management may cause thrombosis in the vascular access site, which is associated with morbidity—eg, site revisions, potential for the need to create a new access site.

The Dialysis Patient: Managing Fistula Complications in the Emergency Department

Because of the possibility of complications involving fistulas, EM physicians should recognize and treat vascular insufficiency, hemorrhage, infection, stenosis, thrombosis, aneurysms, and pseudoaneurysms.

The Risk of Catheter-Related Blood Stream Infections: Femoral vs Internal Jugular and Subclavian

While this topic is still under investigation, recent evidence suggests that femoral lines may be appropriated selected as the line of choice in the right clinical circumstances, particularly in cases where blind avoidance of these lines may increase patient morbidity, such as during emergencies.