Controlling Vascular Access Bleeding

550Qb · Jul 31, 2011

Are you talking about post tx or during tx?

hazyblue · Jul 31, 2011

Post treatment but do feel free to share regarding bleeding during dialysis. I have absolutely no background on dialysis. Thanks in advance.

klm49 · Aug 1, 2011

There is a trick to holding pressure. My employer still uses the SureSeal band aid type dressings. I know not everyone does because of cost. Without the band aid I remove all of the tape. I don't want the tape to hang up on something or prevent the safety device from fully engaging. I then place a gauze folded into a small square over the needle site. I put my middle finger on the gauze and have my index finger straight to catch the loop and slide down the needle guard while the needle comes out. I hold pressure with one hand and actually pull the and engage the safety guard with the other hand. No pressure at the site with the middle fingers until the needle is out then firm pressure directly on the site with fingers 3 and 4. If it is leaking immediately, I shift my fingers slightly for more direct pressure. The biggest thing for me is NO PEEKING. Firm pressure without letting go for at least 3-5 minutes. Then carefully lighten the pressure on the gauze to see if oozing starts before moving the gauze completely. I always become impatient and try to "peek" it is time. I hope this helps.

Tish88 · Aug 2, 2011

How long are these patients bleeding for? They should only bleed for 5-10 minutes post needle removal. I would send the patient for a fistulagram if they bleed longer. This is an indication for stenosis in the access. The heparin that the patient receives should not have a correlation with their post bleeding time, since heparin is turned off at least 1 hr before the end of the treatment and heparin does not have a long half-life and it is dialyzed out during treatment.

When removing a needle, do not apply any pressure to the site until after the needle is completely removed. Then, with one finger hold pressure (not crushing or too firm). Make sure you feel the thrill of the access while holding. If you don't feel the thrill, you are holding too tightly. You don't want to stop or slow the flow through the access; this will lead to clotting the access off.

When holding the site, only hold 1 needle site at a time and don't check for bleeding until 5 minutes has passed. If you check earlier, then your 5 minutes starts over again.

hazyblue · Aug 3, 2011

Ugh, I feel so stupid...

Is using three fingers/compressing a wide area? Last time my patient bleed for about twenty minutes? I sort of notice yesterday that too firm of a hold is bad. I'll check next time if it's me or her vein. Thank you all.

Tish88 · Aug 3, 2011

Using 3 fingers to hold a site will cause too much compression on the access. You only need to use 1 finger - it is only 1 small hole .

Bleeding that long is an indication that there could be a stenosis in the vessel, causing the blood to go to the area of least resistance (the needle hole) as opposed to trying to go through the access and hit up against the stenosis.

Look, listen, and feel the entire length of the access. Is it pulsitile? Does it collapse when the arm is raised or does it stay engorged? Is there a systolic and diastolic component to the bruit?

hazyblue · Aug 4, 2011

Thank you all. I think I've improved in a way. *sigh*

I just want to confirm another subject (still related to bleeding). Today I saw blood coming out of the base of the subclavian access of my patient. I just covered the site with gauze and discontinued the session. I didn't bother to call my head nurse (well I did but the phone line is busy). The arterial pressure was persistent on lower limits anyway and reverse ultrafiltration is happening.

So, question, should I have focused on compressing the access instead of ending the session and returning the blood? Will compressing the access minimize the problem?

(I know I am an idiot... I need an idiot's guide for dialysis T_T )

Okay back to the situation, it was time for me to flush the catheter with heparin+PNSS and I was in doubt because the patient is bleeding. I managed to connect with my head nurse this time and she said that it's alright because the heparin will stay on the catheter only (at least that is what I understood from her). But when the nurse in charge of the patient came with this doctor, they were contemplating that the heparin is prolonging the bleeding (the nurse in charge of the patient has done compression prior). And so, I ask again, did the heparin I injected have an effect?

Thanks in advance. T_T Ah, dialysis, you just drive me close to the window urging me to jump, why welcome me with bleeding...

Tish88 · Aug 8, 2011

when i notice bleeding coming from a catheter site, i replace the dressing with a pressure dressing during the treatment and apply pressure to the site (i use a saline bag). i do not rinse the patient back, but i do stop the heparin infusion that is given during the treatment.

hopefully by the time the treatment is done, the bleeding has stopped. i would instill the heparin in the catheter (only the fill volume amount - no extra).

if the catheter site is still bleeding, i would hold pressure to the site to get it stopped before instilling heparin. i would have the patient sit for a period of time before discharging them, to make sure the bleeding has stopped. also, i would notify the nephrologist of what is going on and document everything that went on and what was done. don't discharge the patient with active bleeding.

my question to you is, does the patient have a ij or subclavian catheter.

according to the kdoqi guidelines, "subclavian access should be used only when no other upper-extremity or chest-wall options are available."

here's the link:

http://www.kidney.org/professionals/kdoqi/guideline_uphd_pd_va/va_guide2.htm

550Qb · Aug 14, 2011

20 minute hold time? Do you think the mid-dose is being given late?

Tish88 · Aug 14, 2011

20 minute hold time? Do you think the mid-dose is being given late?

Heparin last dose should be given up until the last 1 hour for fistulas and grafts. Catheter patients can have heparin during the entire treatment.

20 minute hold times is an indication for the patient to have a fistulagram to see if there is downstream stenosis causing prolonged bleeding time.

Bleeding post should be no longer than 10 minutes regardless of the amount of heparin given during treatment and even if the patient is on coumadin or plavix.