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Post by erinto on Sept 20, 2015 0:21:32 GMT -5
I hope you find this one interesting...it was challenging for me.
81 yo white female, had dialysis earlier in the day. LUE fistula was used. They had trouble getting bleeding to stop. She was sent home at about 7pm. Bleeding recurred 90 mins later. She tried for 2 hours to get it to stop before calling family. She presented to triage, sat out there for 30 mins : ( I removed a dressing to her fistula, which sprayed blood. Direct pressure was held, a second distal puncture site started spraying, so I held two point pressure.
Other than direct pressure, what tests should you order?
How long do you hold pressure, and what is best method?
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Post by Bjs04f on Sept 20, 2015 17:41:42 GMT -5
So what Ive found helpful is thrombipads on top of wound with high pressure for 20 minutes. If thats not improving it, its time for vascular as sometimes they need a revision to be made to the fistula. Things to order would be bmp, coags, cbc. dialysis pts naturally have decreased clotting from elevated urea and other waste substances, decreased platelets and platelet function and are anticoagulated
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Post by erinto on Sept 21, 2015 21:22:55 GMT -5
Correct. I called vascular, who advised me to "sew it". I had never done this. Pressure was held, for 40 mins. Bleeding continued. We looked sewing it up, and a 5-0 or 6-0 NON CUTTING needle with figure 8 or u stitch is used. Elrod requested, and therefore sewed it, as it was still spraying the room. Bleeding slowed. Surgical and pressure dressing applied.
Ptt> 150. Now what?
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Post by Bjs04f on Sept 22, 2015 7:32:51 GMT -5
Not too keen on stitching a surgically made fistula. As far as the PTT, what do they anticoagulate him with at dialysis, is it new, and does he have signs of HIT or other weird anticoagulant related things.
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Post by DD on Sept 22, 2015 16:37:48 GMT -5
Yeah, when you suture those you want to basically be as close to the skin and hole as possible. If you make big deep throws you're more likely to catch/puncture the graft and ruin it or even worse turn your little bleed into a huge bleed! I've assisted a couple, never had to suture one on my own yet but It's pretty much what Rinto said. Worst case scenario is they need a revision which beats dying from acute blood loss.
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Post by erinto on Sept 26, 2015 19:24:47 GMT -5
We did sew it...and bleeding did stop. I wasn't thrilled with the idea either, but it did Work.
No HIT. I have three theories: She got way more heparin than intended, she got a higher concentration than intended, or less likely, she was not processing it normally. In any case, we gave her protamine and she was admitted. The stitch is a NONCUTTING needle, 5-0 nylon in shallow figure 8 or U. Seemed to work well.
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