AV fistulas and lines.

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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.

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Specializes in Nephrology, Cardiology, ER, ICU.

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.

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That is what I thought. Thank you.

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What genius put a PICC in an extremity with an AVF in it???

Not to mention the art-line?

Oy.

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Specializes in ER.

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.

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Also, he had a RUE dvt. Which is the lesser of the two evils ?

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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.

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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.

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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."

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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

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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

Interesting yes, but it's a teeter/totter exercize. Sounds like you done good.

A pt. max'd out on pressors makes for a real fun dialysis experience. The ICU staff blame me when it all goes to hell (lovingly of course) :).

Hope the patient is doing better...full blown sepsis and ARDS does not often bode well.

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Guy is doing better today. He LOOKS alot better, actually has color and looks like he is 49 and not 79.He's on vaso with a touch of Levo (1-5 mcgs/min), both fem lines are removed and has a vas cath in the left IJ. But get this, they put a PICC in the LUE.......He still has the art in the right radial. he has come done on his vent rate and his ABGs look better. It'll be interesting to see how he does, almost time to lighten his sedation and see where we are at.

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