dialysis patients and iv access

[Just Plain Ruff]

recently we had a cardiac arrest patient who was on dialysis.

If there is no available IV access or access is not obtainable not withstanding a Adult IO is it appropriate to place the iv in the patient's shunt?

If it is appropriate to put the iv in the shunt, which side of the shunt should it be placed? I recently had a crew bring in a dialysis patient who had no available IV. It took us many sticks but we did get the IV but in a critical patient is it ok to use the shunt?

[mrmeaner]

I would imagine that most places would prefer any form of an IO to be used instead of attempting to access a shunt as it may be permanently damaged and not useful anyway. My guess would that if it were a possibility, you would have to take specific training, have your med control sign off, and have your protocols approved by your state (assuming shunt access is a part of your state's SOP's for the medic level), kind of like mediport access. Again, just my guess.

[crotchitymedic1986]

wrong, wrong, wrong ---------- know your vein anatomy, you will find a vein

[Camulos]

To answer the question, yes it can be done. Of course whether you are permitted to do it is another question and depends on a few factors. Local protocols, training, pt need etc.

I must stress that I would only ever consider this an absolute last resort. Therefore several failed IV and IO attempts would have to have occurred and the pt would have to be unwell enough to warrant such a drastic measure. And providing the pt has limbs, I can’t see why I would stuff up the IO. Given your scenario was a cardiac arrest one I guess it is also important to keep in mind that certain arrest drugs can be placed down the ETT if IV / IO access truly is a problem.

If you are to access the fistula a few things to keep in mind;

• Make the procedure as clean as possible. I recognise that this may be difficult in this situation however AV fistulas are particularly prone to infection. No use saving the pt now only to have them die from overwhelming sepsis from an infected fistula.

• Must be a last ditch option. All other options have been exhausted and the pt is moribund.

• If the pt has a fistula they already have renal failure. Keep this in mind when making any decision to infuse a large volume of fluids.

• Because the pressure in the fistula can be quite high you may need to infuse fluid under pressure. If a pressure bag is not available a BP cuff around the fluid bag may suffice. But beware applying too much pressure and “blowing” the fistula. Don’t use any smaller than a 10ml syringe because of the high pressures they apply and for some reason a maximum of 150mmHg comes to mind when using a pressure bag / BP cuff. I have no idea where I got that from though. Maybe someone could give some advice here.

• Be prepared for the potential of large haemorrhage if you stuff it up. As the fistula has arterial communication the blood loss from a damaged fistula can be quite large.

• Make sure the shunt is a functional one before attempting to access it. It is not uncommon for inactive shunts to be left in place.

I have personally only ever heard of a fistula being accessed in pre hospital emergency situation once. It was a story reported to me of a pt who was trapped in a car with the only access available to the attending medical team being the lower half of an arm with an AV fistula. This was accessed prior to release of the compressive force in order to administer fluids, bicarb etc. However this pt unfortunately died at the scene. Hopefully not from a ruptured fistula. :oops:

Hope this helps.

Stay safe,

Curse :evil:

[Just Plain Ruff]

I'm getting a mixed bag of responses both here and outside this forum.

A dialysis nurse who does acute dialysis says that yes you can access it but only like some have said as a absolute last resort.

Others Like Crotch are adamately against it.

Many are Go IO if you have to.

Thanks for the responses and thanks to Curse who gave the best response of all.

[Camulos]

wrong, wrong, wrong ---------- know your vein anatomy, you will find a vein

If only it were that simple.

Out of interest crotch how would you have dealt with the scenario I put in my earlier posting of the person trapped in the car with the only access being the lower half of the arm with an AV fistula?

PS. Trunk monkey is cool!!!

Stay safe,

Curse :evil:

[Just Plain Ruff]

If only it were that simple.

Out of interest crotch how would you have dealt with the scenario I put in my earlier posting of the person trapped in the car with the only access being the lower half of the arm with an AV fistula?

PS. Trunk monkey is cool!!!

Stay safe,

Curse :evil:

I'd have gone for the shunt too Curse, there wasn't much to work with there I'll bet. You do what you have to do.

[fiznat]

I probably wouldn't try it but that's likely more because I don't feel I have a firm grasp of shunts, exactly how they work and how I might pick an appropriate spot for puncture. Also I'm thankful that we carry the EZ IO system in our trucks which should prevent this situation from ever becoming a real issue.

That said, with a good understanding of the equipment and a knowledge of the risks in a cardiac arrest patient, I suppose it could be justified. Obviously a last resort though, and it would probably be helpful if you're at the dialysis center already so the staff could help you out with accessing whatever system they've got.

[ERDoc]

Obviously this would depend on your local protocols. In the ER we use it as a last resort in a critical pt. If you don't get access, your pt is going to die. If you use it, it may need to be replaced, but at least your pt has survived to the point where you need to worry about replacing it.

[crotchitymedic1986]

There is nothing wrong with accessing it if you absolutely have to, but too many medics assume dialysis means no veins, which is not always true. I would say I was able to atleast put a 22ga in 95% of the dialysis patients I transported.