Bleeding for MORE than an hour after dialysis from fistula

[Lindia]

Hi guys --    My hubby wanted me to ask for help and opinions.   He is friends with a man in-center at DaVita, who is bleeding for at least an hour, and today was bleeding 1.5 hours after his treatment.    He had a fistulagram last week to check his fistula, he has talked to his nephrologist -  he isn't on blood thinners - none of the doctors or techs have any idea what could be causing this.

This is really miserable for him - and I think he is maybe cutting his treatments short - because it takes him SO LONG to get taped and out of there.

Anyone  have any ideas of what may be happening ? ?     

[lmunchkin]

Well, not knowing info on this gentleman, it could be a couple things causing it. It could be clotted (which would need repair).  Is the fistula new? If it is, what Blood Flow rate are they running him?  To bleed for an hr to an 1.5 hr is alot of blood, unless it is just a trickle & not a gush of blood!  What are they saying (The Professionals that is) the cause is.

One thing is for sure, if it is clotted in anyway, the man is NOT getting enough D.

Hope this helped some, but I havent a clue without more info.  Please keep us posted, ok?

lmunchkin
 

[Hemodoc]

Dialysis patients are like any other patient to the extent that they can get other conditions outside of ESRD related complications. Dialysis patients in general are more prone to bleeding due to platelet dysfunction caused by uremia from CKD. If his treatments are shortened, that is a possible source of making the situation worse. In addition, a stenosis to the fistula can cause prolonged bleeding as well. You didn't report the findings on the fistulagram, but that should have been fixed during the procedure if they found a narrowing called a stenosis.

On the other hand, there are many caused of extended bleeding that his medical team should consider as they would in any patient with a bleeding  diathesis. Here is an abbreviated discussion on issues that doctors might consider evaluating.

http://en.wikipedia.org/wiki/Bleeding_diathesis

Since this appears to be second or third hand information, the most important aspect is that the patient maintains close cooperation with his medical team. However, learning what the usual evaluations are in this situation should only add to the effectiveness of finding out what the underlying cause could be. Lastly, certain medications can cause an increased tendency for bleeding and these should be evaluated carefully as well. The patient will need to discuss his concerns openly with his provider. If they are unable to find the cause, then they might consider a second opinion with a hematologist who study these sorts of issues in great detail.

[Bill Peckham]

I have questions about his needle procedures - for instance is he using lidocane or other injectable numbing agent? Are they sticking in the same area each time or do they move up and down and side to side? Numbing agents can make the skin less elastic; sticking in the same area can damage the skin's ability to close after the needle is removed.


Heparin is such an obvious suspect that I assume they are looking at that but I have heard some reports of heparin being used on the basis of standing orders instead of based on the dialyzor, so I'd want a clot time test and my heparin customized to me.

[Lindia]

.

On the other hand, there are many caused of extended bleeding that his medical team should consider as they would in any patient with a bleeding  diathesis. Here is an abbreviated discussion on issues that doctors might consider evaluating.

http://en.wikipedia.org/wiki/Bleeding_diathesis

Since this appears to be second or third hand information, the most important aspect is that the patient maintains close cooperation with his medical team. However, learning what the usual evaluations are in this situation should only add to the effectiveness of finding out what the underlying cause could be. Lastly, certain medications can cause an increased tendency for bleeding and these should be evaluated carefully as well. The patient will need to discuss his concerns openly with his provider. If they are unable to find the cause, then they might consider a second opinion with a hematologist who study these sorts of issues in great detail.

HemoDoc --- thank you !    Yes, he did have the fistula gram and was told it was fine.   And lmunchkin-  this is bleeding after he comes off the machine, and its not a new fistula --  He holds the sites, and holds them - but nothing helps.   In fact,  his dad is a doctor, and he doesn't know what to make of it -  so these suggestions are great.   He told my hubby - that all his doctors are stumped,  and he hasn't talked to any other doctors than his nephrologist, and the vascular surgeon.    Oh, and I would say he isn't elderly -  probably in his 40's.  THANKS,  and if anyone else has heard of this -  please let me know.

[Lindia]

I have questions about his needle procedures - for instance is he using lidocane or other injectable numbing agent? Are they sticking in the same area each time or do they move up and down and side to side? Numbing agents can make the skin less elastic; sticking in the same area can damage the skin's ability to close after the needle is removed.


Heparin is such an obvious suspect that I assume they are looking at that but I have heard some reports of heparin being used on the basis of standing orders instead of based on the dialyzor, so I'd want a clot time test and my heparin customized to me.

Bill -  thanks for your thoughts -  I will print out these replys, and have my hubby ask him about his needle procedures on Saturday-  I think he has buttonholes - I'm not sure --  if he does, they are fairly new.     I have asked about his heparin - and was told it was the doctors standing order,  but he has talked to his nephrologist since then - so I will ask about the clot time test.   

This has been so hard on him ---  thank you all for your input ...       

[Bill Peckham]

I have questions about his needle procedures - for instance is he using lidocane or other injectable numbing agent? Are they sticking in the same area each time or do they move up and down and side to side? Numbing agents can make the skin less elastic; sticking in the same area can damage the skin's ability to close after the needle is removed.


Heparin is such an obvious suspect that I assume they are looking at that but I have heard some reports of heparin being used on the basis of standing orders instead of based on the dialyzor, so I'd want a clot time test and my heparin customized to me.

Bill -  thanks for your thoughts -  I will print out these replys, and have my hubby ask him about his needle procedures on Saturday-  I think he has buttonholes - I'm not sure --  if he does, they are fairly new.     I have asked about his heparin - and was told it was the doctors standing order,  but he has talked to his nephrologist since then - so I will ask about the clot time test.   

This has been so hard on him ---  thank you all for your input ...       

Oh buttonholes. More questions. The staff are putting in the needles? Are they using dull buttonhole needles? The technique can be used with sharp needles - it was used for years that way until dull needles came on the market - but you must be very diligent for just this reason. Risk of bleeding. Especially if different staff are putting the needles in, if they're using sharps I would say it is a pretty good bet they cut the channel too wide. You would need to establish a new pair of sites and he should be the one to put the needle in and when doing it if you hold the tubing instead of the wings on a buttonhole style needle you'll be much less likely to cut a new path.

[Hemodoc]

The "clot time test" is most likely what we called a bleeding time. This tests more of the platelet factors than some of the other factors. Heparin is measured by a test we call the PTT. This is a very simple and common blood test. It is expected to be high, greater than 150 while on dialysis. The heparin dose could easily be part of the picture. If they have evaluated these things,  a HEMATOLOGIST would be he best specialist to evaluate what is going on in this case. Not only is it an inconvenience, it could turn into a dangerous situation if he loses a lot of blood. If the nephrologist and vascular surgeon cannot answer this situation, I would believe getting a referral to hematologist should be the best place to go.

[lmunchkin]

Let us know, Linda, what they find out!  Hope they get this corrected for him and soon, as it can be very worrisome for you both!

lmunchkin
 

[Lindia]

Ok -  lmunchkin --    I  have printed off all these helpful replies,  and I will give it to him at dialysis today.  Several things could apply -  I think they are doing buttonholes, but he is afraid to stick himself, and that could be part of it, like Bill is wondering.   Of course, Hemodoc is also correct that he need to keep working with his medical team to rule out problems with drugs he is taking and blood problems, etc.   

Thanks so much guys -  I'll let you know how things go.