H

EED THE

H

ERALD

B

LEED

:

An Ominous Warning for Potential Vascular Access Rupture

Prepared by

Pauline Byrne CNS

Vascular Access Coordinator Renal Centre, Wollongong, ISHLD

H

EED THE

H

ERALD

B

LEED

………

AND ACT!!



Clinical Excellence Commission (CEC), 2010

 RCA of fatal bleed from an AV fistula (IIMS)  Review of similar events:  identified five other deaths and nine significant incidents.

 2011: a further death as result of bleeding from an AV fistula  The CEC asked ACI for advice on prevention and education resources.

 This PowerPoint was developed to assist with staff training  as part of a package of resources aimed at staff, patients and carers.



Remember:

Heed the Herald Bleed! ......ACT! ........Save a life!

O

BJECTIVES OF THIS

P

RESENTATION

:

 To define a ‘Herald Bleed’ & potential outcome  To assess Access Functionality & identify ‘Vascular Access at Risk’  Outline one centre’s ‘Acute Management Plan’  Describe the role of stakeholders in management of access at risk  To demonstrate through a case study review: recognition and management of an access at risk of rupture.

W

HAT IS A

: ‘Herald Bleed’

 Definition: ‘Herald’ -

going to happen an indication of something that is

 In relation to either an Arterio-Venous Fistula (AVF) or Arterio-Venous Graft (AVG), a herald bleed refers to either

a small or large spontaneous haemorrhage

.

 A herald bleed may lead to potential vascular access rupture and

loss of life

.

I NTRODUCING M RS .Q

 Mrs. Q- 68 yrs old, ESRD secondary to Wegener’s Granulomatosis  PTFE Loop inserted Right thigh-24/09/2007  Presented ED 2 years post insertion –afebrile, chills, and graft red and painful.

 Blood Culture/Treated IV Antibiotics  Day 7-Abscess over graft/blister like appearance, spontaneous bleed in a Satellite unit on dialysis.

How Can We Identify Access at Risk ?

Look

- Visual Inspection

Feel

-Palpate Thrill and Pulse

Listen

Character of Bruit

Observe

- Access re Pressure Trends during Haemodialysis Treatment.

V

ISUAL

I

NSPECTION

:

Examine Skin Integrity  Is skin thinning over access sites?

 Is infection present?

 Is Infection present with sudden appearance aneurysmal dilatation?

V

ISUAL

I

NSPECTION

:

 Examine Skin Integrity   Presence of Scabs/Blebs Exposed e PTFE Graft

Degraded PTFE graft: ‘One-site-itis”

V

ISUAL

I

NSPECTION

:

 Is access limb oedematous?

 If an upper limb access -the presence of collateral veins, and over chest may indicate central venous stenosis  Is there facial oedema same side as access?

V ISUAL I NSPECTION :

•

Development or increase in size of Aneurysmal/Pseudoaneurysmal Dilatations ?

Aneurysms & Pseudoaneurysms

Aneurysm formation

in primary fistulae can be due to –  Stenosis  cannulation technique such as area puncture  Area puncture technique can cause:   thinning of the skin at puncture sites Bleeding along needles  Longer bleeding time post-dialysis 

Pseudoaneurysms

caused by are  degeneration of graft material combined with venous outflow stenosis  If Pseudoaneurysms have  rapid expansion in size exceeding twice the diameter of the graft + viability of the overlying skin threatened ‘ Are at

risk of Rupture

’ 

Requires Vascular Review

Why You should not cannulate into Aneurysms & Pseudoaneurysms........

 Aneurysms Aneurysms as they enlarge compromise the overlying skin of the fistula, and for those patients where skin layer is thin and prone to infection, is a sign of impending perforation.

 Pseudoaneurysms There is no vessel nor graft in dilated wall- only skin + subcutaneous tissue.

A SSESSING F UNCTIONALITY :

Why palpate and auscultate access?

*Indicators for identifying stenosis*



Palpation

 The ‘Thrill’-at the anastomosis- should be prominent and continuous, with the pulse soft and compressible.

 If stenosis –thrill may only be present in systole, the pulse may be increased and have a ‘water-hammer character’ 

Auscultation

-The bruit should be continuous and low pitch.

 If stenosis- the character of the bruit changes to a high pitch & discontinuous.

A SSESSING F UNCTIONALITY :

What Other Observations are Useful?



Resistance on cannulation

 Can indicate stenosis + if clotting = possible impending thrombosis 

Measuring Trends in Venous & Arterial Pressures

.

 Venous Pressure- trend upwards can indicate venous stenosis  Arterial Pressure- below -150/-250 may indicate inflow stenosis 

Observe Bleeding time post-dialysis

 Post-Dialysis: Prolonged bleeding may indicate proximal stenosis

Diagnostic Confirmation of Access at Risk:



Formal Duplex Assessment:

a non-invasive method of evaluating: arterial & venous stenoses, graft thrombosis, infection, aneurysm, pseudoaneurysm formation and arterial steal.



Access Flow Measurement:

Risk of Access Failure: Fistula flow < 500 mls/min Graft < 600 mls/min.

Trends and setting of individual thresholds advised.

O

NE

U

NIT

’

S

A

CTION

P

LAN

If Access suspected at risk of Rupture:

 Suspected infected fistulae/grafts, identified herald bleed, evident black scab or blebs, sudden onset aneurysmal dilatation, exposed e PTFE grafts: 1.

Do not cannulate:- Renal Registrar/Vascular Registrar review 2.

If infection- septic screen / IV Antibiotics 3.

Exposed e PTFE-treat as infection 4.

Admission 5.

Formal Duplex study of access 6.

Vascular Revision if clinically required

C

ASE

S

TUDY

: M

RS

Q

 Mrs. Q- 68 yrs old, ESRD secondary to Wegeners Granulomatosis  24/09/2007: PTFE Loop inserted Right thigh  Presented ED 2 years post insertion: afebrile/chills/graft red & painful.

 Blood Culture/Treated IV Antibiotics  Vascular review: formal U/S, IV Antibiotics  31/07/2009: ’small spurt’  ‘Blister ruptured - small opening’   31/07/2009: Revision - new PTFE tunnelled, old loop excised.

Graft cultured-MRSA  Day 7: Abscess over graft/blister like appearance; spontaneous bleed in a satellite unit on dialysis.

 IV Antibiotics: Vancomyocin x 6 weeks

O NGOING M ANAGEMENT -

T ARGETING E DUCATION TO S TAKEHOLDERS 

Patients & Carers:

to recognise and inform medical & nursing staff of abnormalities noted with their vascular access, have knowledge of what to do in an emergency.



Nursing Staff:

to recognise a vascular access at risk & report to medical staff, provide & review education to patients on a regular basis, provide patients with a ’Bleeding Emergency Kit’ 

Resident Medical Officers/Medical Registrars:

to recognise the normal attributes of vascular access with high blood flows, to recognise what defines a vascular access at risk, and implement treatment plan as per local policy guidelines

P

OSTER

:

“Heed the Herald Bleed”

What Can Your Unit Achieve?

I N S UMMARY This Presentation has:

 Defined a herald bleed as

‘ ...spontaneous small or large haemorrhage from an AVF/AVG’

 Described: how to assess functionality of an AVF/AVG & to identify types of vascular access at-risk of rupture  Outlined both an acute management plan, and a teaching strategy for relevant stakeholders  Demonstrated through a patient case study: the detection of an access at risk with subsequent medical and surgical management.

R EFERENCES :

 Bachleda et al.,2010,’Infectious Complications of Arteriovenous e PTFE Grafts for Haemodialysis’,

Biomedical Papers of the Medical Faculty of Polacky University in Olomouc,Czech Republic,

pp.13-19  Caksen et al., 2003, ‘Spontaneous Rupture of Arteriovenous Fistula in a Chronic Dialysis Patient’,

The Journal of Emergency Medicine,

pp.224-225 

GOOGLE IMAGES

 Kapoian et al., Dialysis Access and Recirculation, Chapter 5,pp.1-14,www.kidneyatlas.org/book 5.

 Mc Cann et Al.,2008,’Vascular Access Management 1:An Overview’,

Journal of Renal Care,

pp.77-84  Mc Cann et Al.,2009, ‘Vascular Access Management II:AVF/AVG Cannulation Techniques and Complications’,

Journal of Renal Care,

pp.90-98

R EFERENCES (cont.) :

 National Kidney Foundation-KDOQI –Clinical Practice Guidelines for Vascular Access Update 2000,

www.kidney.org/professionals/kdoqi/guidelines

 Tordoir et al.,2007 ‘European Best Practice Guidelines on Vascular Access’,

Nephrology, Dialysis and Transplant Journal.pp.88-117

 Tricht et AL., 2005,’Haemodynamics and Complications Encountered with Arteriovenous Fistulas and Grafts as Vascular Access for Haemodialysis: A Review',

The Annals of Biomedical Engineering

pp.1142-1156  Yan et al.,2009, ’Successful surgical treatment of a ruoture to an arteriovenous fistula aneurysm’, ‘

Cardiovascular Journal of Africa

’, pp.186 197.

A CKNOWLEDGEMENTS : 

Professor Maureen Lonergan

Director Renal Services, Illawarra and Shoalhaven Area 

Dr Kohlhagen, Dr Holt, Dr Greenstein, Dr Wen and Dr Zafiriou

Nephrologists, Wollongong Renal Centre 

Dr Huber, Dr Villalba and Dr Stanton

Vascular Surgeons, Wollongong 

Dialysis Staff

Wollongong/Shellharbour/Shoalhaven 

Mrs. Q

Case Notes