A 39 year old male patient was brought in to the renal day unit electively for removal of his right internal jugular tunnelled vascath. It had been inserted 12 weeks previously when he had unfortunately presented in end stage renal failure, which was thought to be secondary to accelerated hypertension. The tunnelled vascath (permcath) had been inserted for dialysis while a fistula was created and allowed to mature. A left radio-cephalic fistula had been successfully fashioned 10 weeks previously, and this had been successfully needled for the first time by dialysis staff 2 days previously - although they did note that it had bled more than expected after dialysis and required pressure to stop the bleeding.
The SHO removing the line checked clotting and platelet count and consented the patient for removal of the line. The procedure went well under local anaesthesia, with very little bleeding and the patient went home an hour later with information about what to do in the event of bleeding from the removal site as per the hospital protocol. He was due for dialysis the following day.
There were no complications following the procedure. But when the patient arrived for dialysis the following day, the dialysis nurses noted that the area around his arm was quite bruised, and they were unable to needle the patient's fistula. The medical staff reviewed the patient on dialysis, and found that along with marked bruising from the recent dialysis, there was also no palpable thrill (or audible bruit) on examination of the fistula site. When the patient was asked if he had noticed that his fistula had stopped 'buzzing' he said it had noticed it had stopped buzzing the morning after his first dialysis, but thought this was because it had been used for dialysis. An urgent doppler ultrasound scan confirmed no flow in the fistula, and after review by the vascular surgical team, unfortunately it was agreed that the fistula was lost.
The patient needed a further permcath insertion to continue dialysis and was booked for a second fistula formation.
This is a very unfortunate situation. Thrombosis is the most common cause fistula loss, and although the majority are caused by venous stenosis, they can also be caused by hypotension, intravascular volume depletion and (as in this case) prolonged compression. Patients should be counselled that they should always be able to feel a 'buzz' in the fistula, and that if this stops at any point they should get in touch with the renal team immediately - as it might mean the fistula has clotted and may need urgent intervention to 'save' the fistula.
- The main learning point from this case is that the SHO who removed the tunnelled line should have asked about how the patients first dialysis had been via the fistula; and they should have examined the fistula to check it was working before the tunnelled line was removed. Although the fistula would most likely not have been salvageable, had it been found to have clotted off the day before, the patients permcath would not have been removed and he would not have had to undergo a repeat permcath insertion.
- The dialysis staff who needled the fistula for the first time did record in the dialysis records that the fistula required pressure to stop bleeding, but it would also have been prudent for them to inform the renal access team and/or the medical staff directly.
- Perhaps most importantly it should have been re-iterated (and re-inforced) to the patient that should he feel ths buzz stop in his fistula that he should seek medical attention immediately
For further information about renal access in haemodialysis patients see the renal association guidelines on vascular access.