Are YOU Ready for a Vascular Access Rupture?

This blog post was made by Lynda K. Ball, MSN, RN, CNN on March 12, 2015.
Are YOU Ready for a Vascular Access Rupture?

A rupture can happen any time with a fistula or graft. Do you know what to do about it?

Veins are very close to the surface of the skin, so when you cut yourself, a little pressure can stop the bleeding. An artery, on the other hand, is deeper, so the pressure is much higher. Cutting an artery wall will cause blood to spurt with each heartbeat. A vascular access—graft or fistula—connects a vein and an artery, so if it starts to bleed, there is a lot of pressure and it can lose far more blood in a short time than with just a cut. An access rupture is a medical emergency, and you must act quickly. Too much blood loss can quickly make you dizzy and weak, which will keep you from stopping the bleeding. Too many hemodialysis patients died from blood loss because they didn’t act quickly enough.

1: Apply Direct Pressure!

The first thing to do is apply direct pressure over the site with your hand. Do not worry about finding a glove or piece of gauze or a towel, just use your hand. A towel is one of the worst things you can put on a bleeding access—it acts like a wick and pulls the blood into the towel fabric. It is messy to put your hand over the bleeding, but clean up later, after the bleeding stops.

2. Raise the access arm above the heart

The next thing to do is to raise your bleeding arm above your heart (higher than your shoulder). Why? This will slow blood flow due to gravity: it’s more work to get blood to go uphill. If you are near a table and chair, sit down, prop your elbow on the table and hold your arm straight up in the air. Most access ruptures happen away from the dialysis clinic, and a lot happen at home. So, plan what you would do before it ever happens.

3. Call 911

If someone is with you, have them call 911 for you. They need to say that there is a medical emergency. If you are alone, it is harder to call, but practice how to dial with one hand up in the air (and don’t let go of the pressure on your arm!). Some cell phones have an emergency button. If you live alone, pre-program 911 into your cell phone so you only have to push one button. What kind of landline do you have in your house? Practice with one hand how you would get a dial tone and call 911. (But, don’t actually call 911 for practice!) When 911 answers, just yell that you are bleeding and need an ambulance—you don’t have to pick up the hand set.

You may wonder why I didn’t tell you to apply a tourniquet to your access arm. Well, there is some controversy about the use of a tourniquet. Emergency room doctors don’t recommend using them routinely because some are put on so tight that they cut off all the blood supply to the arm or leg, and all the tissue dies and needs to be amputated. Talk with your doctor, especially if you live alone. If you want to be able to use a tourniquet safely, you will need to be trained about where to place it and how tight to make it. Emergency room doctors feel that, in most cases, putting on direct pressure and raising the arm is enough for most bleeding episodes.

What else can you do to prevent a vascular access medical emergency? Take good care of your access. How? Avoid “area puncture”: if you don’t use the Buttonhole technique, leave at least ¼’ (the width of your index finger) from the last scab to the next needle site. This will help keep aneurysms from forming in fistulas and pseudoaneurysms in grafts. On fistulas, cannulating in a 50-cent size area repeatedly:

  • Causes the blood supply to die off

  • The tissue becomes fibrous

  • The blood vessel wall and skin above the access will thin out

Whenever pressure increases in a blood vessel, such as from not taking blood pressure medicine or a stenosis (narrowing) that causes blood to back up, blood backs up and bulges out, causing that “big bump” on an access. As the skin and vessel become thinner and tighter, they could burst like a balloon that has too much air (pressure) in it.

In a graft, the material has no blood supply, so something different happens. When needles are inserted into a same small area, it creates holes in the graft material. These cause blood to leak out, forming a big blood clot that sits on top of a graft to create “big bumps” (pseudoaneurysms). Bacteria love to live in clot material, and a severe infection can occur, because the antibiotics cannot get into the clot to kill the bacteria. Infection can thin and erode the skin above a graft.

Warning Signs to Watch Out For

There are signs that a fistula or graft is at risk of rupture. If you see any of these, call your vascular surgeon and insist on being seen right away. Don’t wait! If it is a weekend, call the after-hours number.

  • Thin, tight, or shiny skin on your access – even a small spot could burst.

  • Discolored areas such as bright pink patches indicates damaged skin or depigmentation.

  • A blister or sore on your access. Any site of infection or weak skin could burst.

  • Large scabs in the cannulation zone. The normal scab size should not be any larger that the diameter of the dialysis needle. Tissue underneath the scab could be eroding and dislodging the scab could cause severe bleeding.

So, using the Buttonhole technique (on a fistula only) or rotating sites will help prevent “big bumps” in a fistula. If you are using area cannulation because it doesn’t hurt as much, talk with your doctor about getting numbing medicine – there are patches, spray, creams, intradermal injection, and ice massage. You may put your life at risk because of the pain, and there are ways to decrease the pain that will allow you to use your access more safely. Your access is your lifeline, and you can be pro-active about its care and know what to do in a medical emergency.

Comments

  • Nilda Badillo

    Jul 01, 2024 10:26 PM

    My nephew is a dialysis patient, he was admitted to the hospital when his brachial fistula/graft ruptured. He lost a lot of blood that lead to his death. We are all devastated coz it was witness by his parents. If hospital staff was able to attend quickly and provide the proper protocol/ standard procedure in that particular case things would have been different. We believe that there was negligence on their part, knowing that the incident happened inside the hospital. We’re up to file a complaint regarding what happened. Do we have grounds to file a complaint?
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    • Dori Schatell

      Jul 02, 2024 3:32 PM

      Hi Nilda. I am so very sorry to hear of the loss of your nephew! Of course his parents were devastated. A dialysis fistula connects a vein to an artery. Veins are closer to the surface of the skin, while arteries are large enough and strong enough to carry the high blood volume that is needed for dialysis. But, if a needle pulls out or a fistula rupture, it takes only about 2 minutes to lose enough blood for it to be fatal. So, even in a hospital, if someone doesn't happen to be RIGHT THERE at the time, it could easily be too late. We are not lawyers and are not able to advise anyone about filing complaints or lawsuits. I'm just trying to help you understand how very quickly a situation like this can become a tragic loss. If a nurse was down the hall and not in the room, it would have been too late, and there was not necessarily any negligence.
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  • Eli

    Apr 19, 2023 7:34 AM

    We just lost my grandmother who was 92 years old to a fistula rupture, she bleed out so fast my mother didn’t know what to do, she lost so much blood. Then she lost consciousness and they could never get her heart rate back up. We were never told something like this could happen, never knew of such a thing but now we know but it had to come at the lost of my grandmother. She didn’t have to go out like that if only we knew
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    • Dori Schatell

      Jul 02, 2024 3:28 PM

      Hi Eli. I just saw your comment today, because I didn't write this blog. I am so sorry about the loss of your grandmother! Having her bleed so much must have been devastating for your mom. Unfortunately, the older we get, the more fragile our blood vessels become. So, while this tragedy could happen to anyone, it is certainly more likely in those who are in their 90s. We try to get the word out about fistula rupture and what to do about it as often as we can. We write the training manual that is used to teach Dialysis Technicians, and this topic is covered in great detail, including teaching patients and families what to do if it happens. We will continue our efforts to prevent this from happening to anyone else.
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  • Kenneth Botha

    Mar 23, 2022 8:27 AM

    Lost more than half my blood when an fistula slided and blood squirted after a sister had dressed the fistula after it had been giving problems in prior dialisis while booked in hospital. Wrong diet was prescribed from start and as an out patient , this all happened on my first outpatient dialisis treatment 2 hours in. The medical staff sent me home with no further dialisis, having blood tests once a week. I have a feeling that I have suffered future harm. Is this a case for medical malpractice?
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    • Dori Schatell

      Jul 02, 2024 3:24 PM

      Kenneth, I am just seeing your comment now, since I didn't write this particular blog. We are not attorneys, and cannot advise you about medical malpractice. While it is hard to know where to start when a chronic illness is new to you, we believe it's YOUR job to learn about your disease and its treatment, so you can protect yourself. That's much easier to do today than it was years ago, as long as you seek out reputable sites online. Which ones are reputable? Generally government sites, healthcare provider sites, and nonprofit advocacy group sites. Don't trust testimonials; they are easily made up. There are no miracle cures for kidney failure, unfortunately. We wish there were!
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  • Dr Gwendolyn Blackshear

    Jan 04, 2022 1:52 PM

    My boyfriend of 9 years just died from the fistula in his arm exploding. He bled to death all alone while I was at work. I'm completely devastated.
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    • Jordan

      May 21, 2022 12:23 PM

      I am so so sorry this happened to your partner. I’ve had my fistula newly put in and been having nightmares about this.
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  • Dori Schatell

    Jun 26, 2020 6:26 PM

    This video shows a new technique to stop fistula bleeding using a bottle top pressed hollow side down over the bleeding site. https://vimeo.com/432362589?fbclid=IwAR33ieI2fVMA-Ylv0BK_4a6mKu-XEouDmBLorGcch1P_CgHqlFI--k09kGg
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  • Dan

    Aug 02, 2019 6:31 AM

    I've had my Fistula since 2004. I was on dialysis for 4 yrs. until my Transplant in 2008. It is now 2019 and the Fistula has grown to an enormous size. I see my nephrologist regularly and, just recently started visits with a vascular surgeon (I just moved and, am new in my area. Looking to establish myself with new MD's). My new nephrologist is concerned with the size of the fistula and feels something should be done (I believe he mentioned a procedure called "banding"),. However, I visited a recommended Vascular Surgeon and he did a CT scan on the Fistula and mentioned that there was no eminent danger(blockages). He mentioned I should wrap it and leave it alone. Kind of concerned myself as reading some info on your site mentions the possibility of a rupture which may be life threatening. Any advice? It certainly would set my mind at ease. Thanks!
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    • David

      Sep 18, 2020 7:52 PM

      I have had my fistula in my arm since 1983. I have had two transplants and I am currently doing PD. My fistula is huge also, but I kept it in so I could use it if my transplant failed, which it did. More recently I had a fistulagram to see if I could use it if I ever needed it. They determined it was not usable as it has narrowed and calcified. My nephrologist recommends I have it undone since I can never use it again away. You and your nephrologist need to weigh out the risks of keeping it in, versus needing it should your transplant fail.
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  • Penny Whitten

    May 13, 2019 4:40 AM

    How can I avoid an under the arm bump?
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  • Ramon

    Jan 19, 2019 10:25 PM

    I have a pic of my fistula; can i Upload it and ask for opinions accordingly based upon this page's educational info?
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