Vascular access hemorrhage can be a fatal complication of hemodialysis, but it is a potentially preventable one. Several studies identified the following risk factors:
- Access-related complications that occurred within six months prior to bleeding deaths, such as: stenosis, local sepsis, aneurysms and pseudoaneurysms
- Repeated trauma
- Uncontrolled hypertension
- Spontaneous bleeding episodes
- Poor site rotation
- Age greater than 50 years
- Limited length of the fistula
- Coagulation abnormalities and anticoagulation treatment
- In rare cases, attempted suicide
How can access ruptures be prevented?
Over half of the access ruptures occurred in AV grafts and approximately three-quarters of the deaths occurred outside the dialysis facilities. Therefore, Education for vascular access care needs to begin with the patient and family members and should include prevention of further damage, signs and symptoms of infection, the importance of talking with the nephrologist and surgeon, and emergency response procedures. Patient education is critical for patient survival post-rupture. Patients need to understand the importance of learning to hold their own cannulation sites in their dialysis facilities so that it will be an automatic response to hold those sites at home, should bleeding occur. Reinforcement of practice needs to occur on a regular basis, such as monthly.
It might be prudent to teach patients who have a high pressure/high flow access, as well as those who live alone, to apply a tourniquet. The medical staff should evaluate vascular access assessment procedures in their dialysis facilities to ensure that patients whose accesses might be at risk for rupture are referred in a timely manner for evaluation and intervention. It is critical that cannulation is done according to Diaverum Policies and Procedures in order to prevent damage to vascular access walls or the tissue within the cannulation zone.
What to do if an access rupture happens?
When an access ruptures, the patient needs to immediately apply direct pressure and elevate the ruptured area of the bleeding above the level of the heart. Patients should be instructed to hold pressure on the access site for at least 10 minutes without peeking. It should also be emphasized to the patient to not wrap a towel around the bleeding site because this can serve as a wick, and the patient will lose more blood unnecessarily. After the bleeding has stopped, it is advisable to observe the patient for an additional 1 to 2 hours for any recurrence of bleeding.
If bleeding does not stop, or if it is obvious that the bleeding cannot be controlled, the patient or anyone else present should call 911 immediately.