Vascular Access Hemorrhage

Although arteriovenous fistula thrombosis and stenosis are more frequently seen, hemorrhage from a vascular access can result in life-threatening blood loss. Dialysis access site hemorrhage typically occurs in the setting of aneurysms, anastomosis rupture, or over-anticoagulation.

ESRD patients also may have bleeding abnormalities stemming from transient thrombocytopenia from anticoagulation during their dialysis session, as well as inherent platelet dysfunction frequently seen in this patient population.¹⁶

Uremia can inhibit platelet aggregation and result in prolonged bleeding times even though other coagulation studies and the platelet count itself will be normal.¹⁷ An abnormal bleeding time, often greater than 15-30 minutes, is the most reliable means to distinguish which uremic patients are at an increased risk of bleeding.

To control hemorrhage, consider the following approaches:

Direct pressure. Any bleeding that warrants an emergency department visit should be immediately controlled with the application of direct digital pressure to the puncture site for 5-10 minutes. Once the bleeding abates, the patient should be observed for rebleeding or early thrombosis for 1-2 hours.

Protamine. Bleeding that occurs within hours of dialysis should prompt consideration of excessive heparin anticoagulation. Under these circumstances, the effects of heparin can be reversed with intravenous protamine administered over 10 minutes. The recommended dose is 1 mg of protamine for every 100 units of heparin given during dialysis.¹⁶ If the heparin dose is unknown, 10-20 mg of protamine should be sufficient.

Gelatin sponges. Commonly seen in the emergency department as Gelfoam®, this adjunct may aid in the hemostasis of bleeding AV grafts. Although studies or case reports of this material being used in this setting are not found in the medical literature, our clinical practice has demonstrated success by including it in the management of this problem.

Gelfoam is a water-insoluble, pliable product that is prepared from purified porcine skin, gelatin granules, and water. Hemostasis is achieved as the gelatinous matrix provides a supporting structure to facilitate the actual clot formation. This mechanism of action does not rely on alteration of the coagulation cascade.¹⁸

To use Gelfoam, the sponge should be removed from its package, and it should be cut to an appropriate size. The sponge may either be applied dry or saturated with sterile, isotonic

sodium chloride solution. The sponge should then be applied with direct pressure to the site of bleeding. Apply sufficient pressure over the sponge to tamponade bleeding, but not so much pressure as to occlude the graft completely. The sponge should be held in place until hemostasis is reached.¹⁸