Fatal Dialysis Vascular Access Hemorrhage

Abstract

Bleeding from dialysis vascular access (arteriovenous fistulas, arteriovenous grafts, and vascular catheters) is uncommon. Death from these bleeds is rare and likely to be under-reported, with incident rates of fewer than 1 episode for every 1,000 patient-years on dialysis, meaning that dialysis units may experience this catastrophic event only once a decade. There is an opportunity to learn from (and therefore prevent) these bleeding deaths. We reviewed all reported episodes of death due to vascular access bleeding in Australia and New Zealand over a 14-year period together with individual dialysis units' root cause analyses on each event. In this perspective, we provide a clinically useful summary of the evidence and knowledge gained from these rare events. Our conclusion is that death due to dialysis vascular access hemorrhage is an uncommon, catastrophic, but potentially preventable event if the right policies and procedures are put in place.

A prototype line clamp for venous access bleeding in hemodialysis: A prospective cohort study

“…Fatalities due to venous needle dislodgement (or venous port disconnection) during HD have been reported, both incenter and at home . Vascular access bleeding is brisk and can be catastrophic within a short time.…”

“…Fatalities due to venous needle dislodgement (or venous port disconnection) during HD have been reported, both incenter and at home. 2 Vascular access bleeding is brisk and can be catastrophic within a short time. A review of the New York City Office of Chief Medical Examiner death certificates over an 8-year period identified 100 deaths due to hemorrhage from an AV fistula or graft.…”

The use of anticoagulants in chronic kidney disease: Common point of view of cardiologists and nephrologists

“…Moreover, the type of vascular access is also significant for bleeding risk. Damages or infections of central vascular catheters or synthetic arteriovenous grafts, patient-dependent factors, bystander diseases, administered medications, an ability to take care of angioaccess, or finally factors related to the hemodialysis procedure increasing the risk of bleeding complications [11,12]. Although no dose adjustment is required in patients with moderate CKD, caution is recommended [13,14].…”

Briefly Noted

“…Infection or skin integrity issues (e.g, thinning) were present in 52% of AV access bleeds. The presence of a thigh graft was usually not noted but when it was reported (14 cases) it was often (5 cases) found to be the source of bleeding …”

“…The presence of a thigh graft was usually not noted but when it was reported (14 cases) it was often (5 cases) found to be the source of bleeding. 8 Venous stenosis (by ultrasound) was present 6 weeks after AV fistula creation in 30% of 602 patients. Stenosis was associated with a 2.0 fold increased risk of maturation failure after adjustment for case mix, fistula location and whether patient was already on chronic dialysis.…”