AV fistulas and lines.

  1. 0
    Recently, I had a pt admitted to the ICU with a LUE av fistula and a LUE Picc line. He was hypotensive, so he got an art line... In his left radial. I was always under the impression that NO lines should be in the extremity, we ended up pulling the presumed infected Picc so that went away. We also switched it to a right radial. It appears the fistula was dampening the art line. Are there any lines that can go in that arm, or should it be a avoided to begin with? The fistula was functional although not in use and he bought him self cvvh.
  2. 19 Comments so far...

  3. 4
    An arm with a fistula or graft is considered compromised so nothing (BPs, IV, lab draws, lines of any kind) should be placed in that arm.
    beeker, SmilingBluEyes, missladyrn, and 1 other like this.
  4. 0
    That is what I thought. Thank you.
  5. 5
    What genius put a PICC in an extremity with an AVF in it???

    Not to mention the art-line?

    Oy.
    nurse671, beeker, brillohead, and 2 others like this.
  6. 1
    We will occasionally start a PIV in a fistula arm in the ED, but generally only after getting an OK from the nephrologist. And, it's always a very distal line, like hand/wrist. It's only meant as a very temporary stop gap until someone can get a port/picc etc.
    Guttercat likes this.
  7. 0
    Also, he had a RUE dvt. Which is the lesser of the two evils ?
  8. 0
    Quote from MLB55
    Also, he had a RUE dvt. Which is the lesser of the two evils ?
    Oof. This is a tough scenario.

    Dialysis patients are notoriuous for IV/CL access nightmares. So many of them not only have an extensive history of fistula/graft placements and revisions, central (dialysis) cath placements, but crap vasculature anyway.

    An Art line in an extremity with a functioning fistula/graft will likely produce inaccurate readings due to diverted arterial blood flow (depending on a few factors).

    The DVT in the other arm...not an uncommon occurence in patients who have or have had a central line: it can cause central venous stenosis. Attempting to put a line in (for infusion purposes) an extremity with a known DVT is a bad idea.

    Attempting a PICC in the dialysis graft arm, is just plain stupid if a picc is not absolutely necessary. PICC's can cause infection, CVC stenoses/clots and thereby compromise future prospects for surgical revision intervention (i.e., basillic vein transposition) on a dialysis access if that access were to fail at some point...

    ...dialysis access is the patient's long term lifeline, and every time there is an insult/compromise their vasculature, it is risking future availability of options. Remember, dialysis grafts/fistulas are prone to failure, which is why you might see patients come through with multiple revision/surgeries.

    Once they've run out of access options, that can be the end of the road for some.
    Last edit by Guttercat on Mar 20, '12
  9. 0
    Hey guttercat I appreciate the info.I can not state whether or not the Picc was placed on this admission, but he definately had it before he came to us (ICU).. he had been admitted for stem cell 2/t mm. The art line on the other hand was definately put in by the micu team, it was indeed giving us dampened pressures.L IJ 3L was placed, as well as a right fem quinton for CVVH. His pressor requirement was way up, along with sedation, calcium, ammiodarone, plt transfusions and multiple IV antibx - he received a left fem 3L. I took care of him day 3, we were able to come off dopa. On vaso, 20 of Levo and 180 of neo. As opposed to 5 of dopa, on vaso, Levo and neo maxed. He must of needed that Picc for the stem cell tx.
  10. 0
    Quote from MLB55
    Hey guttercat I appreciate the info.I can not state whether or not the Picc was placed on this admission, but he definately had it before he came to us (ICU).. he had been admitted for stem cell 2/t mm. The art line on the other hand was definately put in by the micu team, it was indeed giving us dampened pressures.L IJ 3L was placed, as well as a right fem quinton for CVVH. His pressor requirement was way up, along with sedation, calcium, ammiodarone, plt transfusions and multiple IV antibx - he received a left fem 3L. I took care of him day 3, we were able to come off dopa. On vaso, 20 of Levo and 180 of neo. As opposed to 5 of dopa, on vaso, Levo and neo maxed. He must of needed that Picc for the stem cell tx.

    Holy smokes, complicated patient all the way around. Great scenario/case study, so thanks for posting.

    I'd (almost) be willing to bet a year's salary the picc was placed during this admission. This sounds like the kind of patient where decisions are made "on the fly" based upon the immediate need(s) at hand.

    And a patient such as this, has rapidly changing needs which does not always translate well into foreseeing and planning in advance for "the next problem."
  11. 1
    He was that classic renal pt that got septic. I was there the day he got admitted, report sounded something like "last bp was 30/20"... Give fluids, intubate, put in lines, and than maxed on four pressors and cvvh. I was happy to see him headed in the right direction, the day before he had been tachy 180s-200s. That touch of dopa and max on Levo + sepsis... He was not looking good.I handed him over with maps in the 60s, HR in the 90s-120s. Still very very sick, but not actively circling the drain. And yes, the team was not worried about his long term access. He was also in ARDS. His plt goal was >10, pao2>55, map >55
    Guttercat likes this.


Top