Why Fistulas Bleed?

• Frequent puncture to access fistula with 16G or larger needle
• Uremic platelet dysfunction
• Supra-therapeutic anticoagulation with heparin
• Fistula abnormalities (pseudoaneurysm, stenosis, infections)
• Semi-arterial pressure so can bleed a lot

Management

• Usual ABC’s + resuscitation, obtain IV access
• Direct pressure is 1st line for 10-15 minutes
• Gentle pressure as excessive direct pressure can lead to iatrogenic fistula thrombosis
• Can also provide pressure proximal and distal to fistula to avoid direct pressure
• If resolution → observe in ED x 2 hours for re-bleeding and US to assess for AV fistula complications
• Can try topical hemostatic agents like gelfoam or recombinant thrombin but often need a dry area for those to work
• Consider protamine as heparin often used to prevent clotting → 1 mg of protamine for every 100U heparin used during dialysis
• IV DDAVP has been shown to decrease bleeding time in patients with uremic platelet dysfunction → 0.3 mcg/kg IV over 10 minutes → contraindicated in hyponatremia, CHF
•  If above measures fail:
• Consult vascular
• Consult nephrology as well
• If pt is very unstable and at risk of dying → tourniquet or excessive direct manual pressure → patient at risk for limb ischemia and fistula thrombosis.
• +/- figure of 8 stitch → some ED providers do this but others advice discussing in consultation with vascular surgery and nephrology as access is patient’s life line

References

• https://www.acep.org/Clinical---Practice-Management/Focus-On--Dialysis-Access-Emergencies/#sm.000c32lta121idefsga2as323xp3z