Last week, I had a patient who came from dialysis with bleeding from his AV graft. He had completed his entire dialysis session without any problems, and when they removed the needle from his graft, he started having bleeding. Pressure was applied, but to no avail. By the time he got to us, intermittent pressure had been applied for an hour without stoppage of the bleeding. I was going through some different treatment options, and thought it would make a good blog post. For clarification, this guy was having definite arterial bleeding. Not shooting-across-the-room type of arterial, but pulsatile with a significant amount of blood loss.
What I ended up doing is placing two figure of eight stitches. Here is a very cool YouTube showing this procedure: https://www.youtube.com/watch?v=toFiGSfesZk
You should definitely know how to do this. I also talked with the senior vascular surgery resident. He said he likes to take a piece of gelfoam, place it over the spot that’s bleeding, hold gentle pressure for 10 minutes (not hard pressure; that could occlude the graft and cause it to clot off = bad). He assured me that this works even for arterial bleeding.
A quick search yielded these recommendations from ACEP: https://www.acep.org/Clinical—Practice-Management/Focus-On–Dialysis-Access-Emergencies/
Note that the authors are former SGH residents and Dr Barton! Very cool!
If the patient is not having arterial bleeding and is more just oozing, I like DDAVP. You also have to consider protamine if the patient is coming from dialysis because they do get heparin during dialysis.
Take home points: consider throwing in some figure-of-eight sutures, using gelfoam, or possibly using medication (DDAVP, protamine) to stop the bleeding from an AV graft/fistula.
What other bleeding problem is DDAVP used in? How does it work? Why does it help dialysis patients?