Monday, September 19, 2016

Fistula complications

emDocs - September 18, 2016 - Author: Simon E - Edited by: Robertson J and Koyfman A
Nearly 400,000 individuals in the United States are maintained on HD therapy. With incident cases of ESRD reaching nearly 21,000 annually, and vascular access complications accounting for 16 to 25% of hospital admissions, understanding of the appropriate management of AV fistula complications is paramount for the emergency medicine physician..."
Key Pearls

  • Fistula complications = 16-25% of hospital admissions for HD patients
    • DASS => complication of operative creation of a HD fistula
      • Diagnosis based upon presentation and PE
        • Cool/painful limb + diminished or absent distal radial pulse, palpable only with compression of the dialysis access site => Vascular Consult
    • Hemorrhage
      • #1 = direct pressure
      • Gel foam, rhThrombin +/- DDAVP in consultation with a specialist are options
      • Consider protamine for heparin reversal if recently received dialysis
    • Infection
      • Common cause of morbidity = cover for Staph and Strep
      • Use US to differentiate perivascular cellulitis from local abscess, infected hematoma or infected thrombus.
        • Perivascular cellulitis => Vancomycin (+ gentamycin if gram negatives suspected)
        • Abscess, hematoma, thrombus => Antibiotics + vascular consult for possible OR
    • Fistula Stenosis
      • Patients present with extremity pain +/- chest wall edema
        • Order Doppler US
          • Abnormalities = consult vascular => PTCA
        • Fistula Thrombosis
          • Fistula has absent bruit or thrill = vascular consult => thrombectomy vs. thrombolysis
      • Fistula Aneurysm or Pseudoaneurysm
        • Patients present with extremity pain, compression neuropathy, or hemorrhage secondary to skin erosion.
          • Doppler US => vascular consult for abnormalities