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Haemorrhages from arteriovenous fistula | Signal

Reference number
Issue date14 February 2011

This Signal is about life-threatening haemorrhages from arteriovenous fistula.

A sample incident reads:

"District Nurse carrying out routine visit to renal patient at home to change dressing. Patient had AV fistula in situ on her arm. Whilst changing the dressing there appears to have been some problem with the fistula and as a result the patient began to bleed. District Nurse unable to stop bleeding and patient died."

An arteriovenous (AV) fistula is created through surgery and links an artery with a vein for use in renal dialysis. AV fistulas have to be treated with great care to maintain blood flow. Patients should not have their blood pressure taken on that arm, nor routine bloods taken, and only gentle direct pressure is used to stop bleeding after the site has been punctured.

Renal unit staff observe the patient for haemorrhage during dialysis. However, haemorrhage can also occur between dialysis sessions, especially if the patient has skin lesions on the site of the AV fistula. As the AV fistula has arterial blood flow, any haemorrhage can rapidly become life threatening.

National Reporting and Learning System (NRLS) data were reviewed for incidents reported from 1 November 2003 to 7 April 2010 to identify haemorrhages from AV fistulas occurring outside dialysis sessions. We identified two fatal and nine very serious haemorrhages from AV fistulas in patients’ own homes, and two fatal and five very serious haemorrhages on wards.

Other reports suggested that community, paramedic, emergency department and ward staff did not always appreciate the life threatening nature of haemorrhage from AV fistula. Some reports suggested that some staff might confuse the routine care of an AV fistula with the care appropriate in a life-threatening emergency. As a result they were reluctant to apply pressure to the AV fistula site or to use tourniquets even after blood loss leading to collapse.

This Signal can be used to remind staff outside renal specialties who may encounter patients who have AV fistulas of the rare but important risk of life-threatening haemorrhage. Staff should also be aware of local advice or protocols that would help them manage any haemorrhage safely and effectively.

Please contact us with information about your initiatives to reduce risk in this area.

Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.