Are YOU Ready for a Vascular Access Rupture?
A rupture can happen any time with a fistula or graft. Do you know what to do about it?
Veins are very close to the surface of the skin, so when you cut yourself, a little pressure can stop the bleeding. An artery, on the other hand, is deeper, so the pressure is much higher. Cutting an artery wall will cause blood to spurt with each heartbeat. A vascular access—graft or fistula—connects a vein and an artery, so if it starts to bleed, there is a lot of pressure and it can lose far more blood in a short time than with just a cut. An access rupture is a medical emergency, and you must act quickly. Too much blood loss can quickly make you dizzy and weak, which will keep you from stopping the bleeding. Too many hemodialysis patients died from blood loss because they didn’t act quickly enough.
1: Apply Direct Pressure!
The first thing to do is apply direct pressure over the site with your hand. Do not worry about finding a glove or piece of gauze or a towel, just use your hand. A towel is one of the worst things you can put on a bleeding access—it acts like a wick and pulls the blood into the towel fabric. It is messy to put your hand over the bleeding, but clean up later, after the bleeding stops.
2. Raise the access arm above the heart
The next thing to do is to raise your bleeding arm above your heart (higher than your shoulder). Why? This will slow blood flow due to gravity: it’s more work to get blood to go uphill. If you are near a table and chair, sit down, prop your elbow on the table and hold your arm straight up in the air. Most access ruptures happen away from the dialysis clinic, and a lot happen at home. So, plan what you would do before it ever happens.
3. Call 911
If someone is with you, have them call 911 for you. They need to say that there is a medical emergency. If you are alone, it is harder to call, but practice how to dial with one hand up in the air (and don’t let go of the pressure on your arm!). Some cell phones have an emergency button. If you live alone, pre-program 911 into your cell phone so you only have to push one button. What kind of landline do you have in your house? Practice with one hand how you would get a dial tone and call 911. (But, don’t actually call 911 for practice!) When 911 answers, just yell that you are bleeding and need an ambulance—you don’t have to pick up the hand set.
You may wonder why I didn’t tell you to apply a tourniquet to your access arm. Well, there is some controversy about the use of a tourniquet. Emergency room doctors don’t recommend using them routinely because some are put on so tight that they cut off all the blood supply to the arm or leg, and all the tissue dies and needs to be amputated. Talk with your doctor, especially if you live alone. If you want to be able to use a tourniquet safely, you will need to be trained about where to place it and how tight to make it. Emergency room doctors feel that, in most cases, putting on direct pressure and raising the arm is enough for most bleeding episodes.
What else can you do to prevent a vascular access medical emergency? Take good care of your access. How? Avoid “area puncture”: if you don’t use the Buttonhole technique, leave at least ¼’ (the width of your index finger) from the last scab to the next needle site. This will help keep aneurysms from forming in fistulas and pseudoaneurysms in grafts. On fistulas, cannulating in a 50-cent size area repeatedly:
Causes the blood supply to die off
The tissue becomes fibrous
The blood vessel wall and skin above the access will thin out
Whenever pressure increases in a blood vessel, such as from not taking blood pressure medicine or a stenosis (narrowing) that causes blood to back up, blood backs up and bulges out, causing that “big bump” on an access. As the skin and vessel become thinner and tighter, they could burst like a balloon that has too much air (pressure) in it.
In a graft, the material has no blood supply, so something different happens. When needles are inserted into a same small area, it creates holes in the graft material. These cause blood to leak out, forming a big blood clot that sits on top of a graft to create “big bumps” (pseudoaneurysms). Bacteria love to live in clot material, and a severe infection can occur, because the antibiotics cannot get into the clot to kill the bacteria. Infection can thin and erode the skin above a graft.
Warning Signs to Watch Out For
There are signs that a fistula or graft is at risk of rupture. If you see any of these, call your vascular surgeon and insist on being seen right away. Don’t wait! If it is a weekend, call the after-hours number.
Thin, tight, or shiny skin on your access – even a small spot could burst.
Discolored areas such as bright pink patches indicates damaged skin or depigmentation.
A blister or sore on your access. Any site of infection or weak skin could burst.
Large scabs in the cannulation zone. The normal scab size should not be any larger that the diameter of the dialysis needle. Tissue underneath the scab could be eroding and dislodging the scab could cause severe bleeding.
So, using the Buttonhole technique (on a fistula only) or rotating sites will help prevent “big bumps” in a fistula. If you are using area cannulation because it doesn’t hurt as much, talk with your doctor about getting numbing medicine – there are patches, spray, creams, intradermal injection, and ice massage. You may put your life at risk because of the pain, and there are ways to decrease the pain that will allow you to use your access more safely. Your access is your lifeline, and you can be pro-active about its care and know what to do in a medical emergency.