I almost lost my fistula thanks to staff stupidity

[RightSide]

In my dialysis treatment yesterday, at around 5 PM (approx. one hour into the treatment), real trouble began:

Evidently air bubbles in the extracorporeal blood circuit initiated blood clotting.  Pretty soon the transducers had clotted, followed by the tubing. 

My tech disconnected me from the machine (leaving the two needles stuck in my fistula), but she couldn't clear the clots.  Two nurses both tried and failed too.  Over and over they tried, without success.

As time passed, the clotting continued to cascade until the blood in the arterial needle clotted up too.  Now the whole blood circuit was gone.

Even worse, when a nurse removed the arterial needle from my fistula, the bruit and thrill stopped.  She tried to listen for the bruit with her stethoscope but could hear nothing, even though we weren't pressing hard on the arterial site to stop it from bleeding.  Evidently the blood clotting in the needle started to cascade into the fistula causing clotting to be initiated in there too.

Contemplating the loss of my fistula was very scary--and I got very upset.

In the end, I lost the blood in the clotted blood circuit, despite all their attempts.  Then, my nurse created a new puncture for a fresh arterial needle, and set up a new dialyzer and blood circuit, and restarted my dialysis session.  Perhaps some clot had worked its way into the fistula from the arterial needle.  Because when the dialysis session restarted, all of a sudden the bruit and thrill returned out of nowhere, suggesting that clot had worked its way loose?  But quite a lot of time was lost, perhaps 40 minutes.

This sequence of fiascos should not have happened. Evidently the protocol is to keep trying and trying and trying to get the patient's blood back into his body, no matter how long it takes, no matter what.  Why??? Less than 300 ml of blood can be lost that way; with Aranesp or other ESAs, I can make new red blood cells quite quickly to replace the ones I have lost.  What I cannot do so easily is replace the fistula.  I worked very hard to get that fistula--it took four operations over a period of fifteen months.  It's not worth risking it for a lousy 300 ml of blood.  And getting as much time as possible on dialysis is more important than the lousy 300 ml of blood too.

What they really need is a decision point:  Say, if after 15 minutes of attempts, they still can't get the patient's blood back into his body, they should GIVE UP and set up a new blood circuit.  Don't keep throwing good blood after bad.

P.S.  In case you're wondering why I don't take more Heparin, the answer is that I used to.   My neph cut my heparin dose after I kept bleeding out at the end of the sessions.  On several occasions, no matter how much they clamped my needle sites, my blood was pouring out of my arm all over the floor.  We'll try a compromise choice--just a tad more heparin and see how that goes.

P.P.S.  I also wonder why, when the staff realized they would have to rebuild the entire blood circuit, they didn't inject some saline into the needles to flush the stale blood out of there.  Wouldn't that have prevented clots from forming inside the needles?  When I asked about that, they replied "that isn't standard procedure."  If the "standard procedure" results in a mess like this, then the procedure should be changed.

[greg10]

I am sorry to hear this, I was wondering where you have been.

In our NxStage training, we were told you can't really go wrong with adding more saline (within reasonable amount, a few hundred ml).  The NxStage cycler is also pretty good about sounding the alarm with pressure build up from clotting.  NxStage's short coming is that it doesn't come with a heparin pump, but you can add an externa syringe pump when needed.

All I can say is there is often a lack of training in technicians in encountering unfamiliar situations during dialysis.  They don't necessarily know what is the most important procedure to take for the best outcome for the patient.  It is a difficult situation for all involved.  I don't think they were trying to hurt you, but they should have known better.

[KICKSTART]

Does you machine not alarm as soon as air bubbles are detected? I had that happen to me the other week and it alarmed micro bubbles detected, straight away they stop the machine and (dont ask me how) but with the use of a syringe can draw off the blood from a chamber which results in rectifying the problem. Failing that dialysis would be stopped straight away the machine stripped and a fresh machine brought out primed and ready to go. As you say its approx 250-300mls of blood which isnt really that much to lose, all things considered !

[BigSky]

Here its usually no more than 3-4 minutes before they dump everything in such events.

Standard procedure is too clear the needle lines at all times when someone is disconnected from the machine.... for anything.

Here for those that do not use heparin they run a little heparin through the tubing and filter in the beginning before hookup.  During they run they flush the system with saline to try to keep it clear.  Usually adds .2 each time to the person goal for each time they do it.

Does you machine not alarm as soon as air bubbles are detected? I had that happen to me the other week and it alarmed micro bubbles detected, straight away they stop the machine and (dont ask me how) but with the use of a syringe can draw off the blood from a chamber which results in rectifying the problem. Failing that dialysis would be stopped straight away the machine stripped and a fresh machine brought out primed and ready to go. As you say its approx 250-300mls of blood which isnt really that much to lose, all things considered !

If there is little air bubbles in the header the machine doesnt detect them.  In the header they can let clotting start to occur. 

[okarol]

  That's a scary story. Given what you've been through I can imagine the panic feeling when the thrill was not there. I hope the techs learned something from this experience.

[boswife]

That was awful and i could feel that fear!  Im getting a bit annoying i think to the techs because im always asking the 'why's' of what their doing, and correcting if need be     I just cant help myself as if they mess him up, im going to have to deal with a bad fistula and im not experienced yet..  I feel horrified that you had to sit and take this!!!  You and your fistula are too important for them to play around..  Dang!! I hope none of that happens again!!

[kitkatz]

I have been known to clot the dialyzer and lines.  The staff where I am works a short time to fix it,then will initiate a new set-up for the machine.

[RightSide]

Here its usually no more than 3-4 minutes before they dump everything in such events.

Standard procedure is too clear the needle lines at all times when someone is disconnected from the machine.... for anything.

Here for those that do not use heparin they run a little heparin through the tubing and filter in the beginning before hookup.  During they run they flush the system with saline to try to keep it clear.  Usually adds .2 each time to the person goal for each time they do it.

Would you mind if I forwarded your post to the head nurse at our center?  It sounds like the standard procedures at your center are better for handling this eventuality than the procedure at my center--which seems to be "Try any damn thing you can think of and just keep trying it until you stumble on something that works".

[BigSky]

Here its usually no more than 3-4 minutes before they dump everything in such events.

Standard procedure is too clear the needle lines at all times when someone is disconnected from the machine.... for anything.

Here for those that do not use heparin they run a little heparin through the tubing and filter in the beginning before hookup.  During they run they flush the system with saline to try to keep it clear.  Usually adds .2 each time to the person goal for each time they do it.

Would you mind if I forwarded your post to the head nurse at our center?  It sounds like the standard procedures at your center are better for handling this eventuality than the procedure at my center--which seems to be "Try any damn thing you can think of and just keep trying it until you stumble on something that works".

Go ahead.


I might add that I believe Nx Stage also recommends in the case of a power outage that blood should be given back after 2 minutes  if power does not return because of the clotting issue.    This would seem to indicate that blood in the circuit is subject to loss to clotting if not returned in a timely manner after those 2 minutes.

[thegrammalady]

all centers are not created equal, even among centers from the same company. what is standard at one center is not standard at another. sucks doesn't it!

[Riki]

I have been known to clot the dialyzer and lines.  The staff where I am works a short time to fix it,then will initiate a new set-up for the machine.

I do too.  They stopped heparin on me for a while because it was making my hair fall out and they had to do flushes every half hour in order to keep me from clotting the machine..

Rightside, not flushing the lines once you were disconnected from the machine to keep the needles from clotting.. that's beyond my comprehension.  I've had clots in those line before too, and they used saline flushes (prefilled saline syringes) to pull the clots out. That was kinda gross, cuz even when it was mixed with the saline, the blood was kinda syrupy.  The got the clots out, though.

[calypso]

That isn't standard procedure=I didn't think of doing that at the time even though it was the right thing to do.