Blood leaking from fistula during dialysis. Help!

[jo]

Hi,

For the past four dialysis sessions, blood starts leaking from the fistula and they had to stop dialysis for my mom. Does this mean there is a problem with the fistula? She has also been having a low grade fever for the past two weeks accompanied with chills which got worse yesterday and today. We are at the ER right now. Any advice would be appreciated. Thanks.

[PrimeTimer]

Hi,

For the past four dialysis sessions, blood starts leaking from the fistula and they had to stop dialysis for my mom. Does this mean there is a problem with the fistula? She has also been having a low grade fever for the past two weeks accompanied with chills which got worse yesterday and today. We are at the ER right now. Any advice would be appreciated. Thanks.

Because of the fever, you have her in the right place by being at the hospital. The sooner they can find the source of the fever, the better off she will be. They will run tests and swabs for infections and if they have to and once they know what type of infection she has, they will give her antibiotics thru an IV and should have her feeling better in no time. So you are at the right place! And hopefully while they have her there, you can ask them to have a vascular surgeon check her fistula and maybe do a fistulagram, that way, if there is any problems with her fistula or buttonholes, they can perform the correction right then and there so she can continue with dialysis at the hospital and not skip any treatments. Remaining on a dialysis schedule is very important! The time that my husband's buttonholes would bleed from the sides during treatment were because of high blood pressure or because he moved his arm and ended up moving the needle and widening the buttonhole. In that case, the nurse had to establish a new buttonhole but this did not cause him to miss treatments. So I really hope you let her Neph know about all this, if not already, and insist on a vascular surgeon checking her fistula. Hope you're able to get some rest while your mom is in the hospital, take good care of yourself because running back and forth to the hospital and dealing with the staff takes a lot out of a person. I know! Been there, done that! If you have to, rest up first and go back a little later in the morning instead of first thing, just make sure you take care of yourself because you won't be of any good if you are too exhausted and end up sick. Do hope it goes better for you guys! 

And don't forget, don't let the nurses stick needles for tests, iv's or injections in her fistula or in the same arm as the fistula! I drew a note on some surgical tape and gently taped it to my husband's fistula arm to remind them.

[jo]

Hi,

For the past four dialysis sessions, blood starts leaking from the fistula and they had to stop dialysis for my mom. Does this mean there is a problem with the fistula? She has also been having a low grade fever for the past two weeks accompanied with chills which got worse yesterday and today. We are at the ER right now. Any advice would be appreciated. Thanks.

Because of the fever, you have her in the right place by being at the hospital. The sooner they can find the source of the fever, the better off she will be. They will run tests and swabs for infections and if they have to and once they know what type of infection she has, they will give her antibiotics thru an IV and should have her feeling better in no time. So you are at the right place! And hopefully while they have her there, you can ask them to have a vascular surgeon check her fistula and maybe do a fistulagram, that way, if there is any problems with her fistula or buttonholes, they can perform the correction right then and there so she can continue with dialysis at the hospital and not skip any treatments. Remaining on a dialysis schedule is very important! The time that my husband's buttonholes would bleed from the sides during treatment were because of high blood pressure or because he moved his arm and ended up moving the needle and widening the buttonhole. In that case, the nurse had to establish a new buttonhole but this did not cause him to miss treatments. So I really hope you let her Neph know about all this, if not already, and insist on a vascular surgeon checking her fistula. Hope you're able to get some rest while your mom is in the hospital, take good care of yourself because running back and forth to the hospital and dealing with the staff takes a lot out of a person. I know! Been there, done that! If you have to, rest up first and go back a little later in the morning instead of first thing, just make sure you take care of yourself because you won't be of any good if you are too exhausted and end up sick. Do hope it goes better for you guys! 

And don't forget, don't let the nurses stick needles for tests, iv's or injections in her fistula or in the same arm as the fistula! I drew a note on some surgical tape and gently taped it to my husband's fistula arm to remind them.

They did the following tests at the ER:
ECG
Basic Metabolic Panel
Blood Gas Analysis With Electrolytes (Aegis)
CBC With Plt Count And Auto Diff
Blood Culture
Peripheral IV   
US ED Ultrasound Peripheral IV   
Chest Xray
Urinalysis   
All of the results came back negative except the urinalysis which showed some urinary tract infection which the primary care physician already found out 3 days ago and put her on antibiotics. I am not sure if any other tests should have been done to figure out the cause of the fever and chills. We asked them to check her fistula. Looking at her fistula appointment scheduled on Monday, they said the nephrologist clinic will take care of that on Monday. We asked them three times if they can check the fistula but they said no. Sometimes I get really upset with these responses. She has dialysis tomorrow and I am worried if the leaking will happen again until they figure out what's going on. The blood leak has been going on for the past 4 or 5 treatments. We are really stressed out and worried.
She never moves her arm during treatments. It's just the techs are not very good with the buttonhole technique and the fistula became a problem when one of the new techs poked her really hard. My mom felt that the position was shifted while he was trying to poke her. So you are saying establishing a new buttonhole is what needs to be done? Thanks.

[Michael Murphy]

Once a month the dialysis center should be doing a test called "Access Flow".  The purpose of this test is to check how well the patients access ( in this case it's the fistula) is performing.  They the compare this months resul against last months results if it changes they will refer you to a vascular surgeon who will probably have a ultra sound done on the fistula and the arteries and veins connected to the fistula.  If problems are found generally a angioplasty is performed on the fistula.  Occasionally I have some minor seepage around my needles.  But my access flow tests are always good.

[PrimeTimer]

Hopefully a new buttonhole will not need to be established. The vascular surgeon will be able to tell you if her fistula has good blood flow or not. As for the buttonholes, it's important that the needles be inserted at the same angle and depth each and every time to form a "track" inside (picture a small tunnel that the needle slides down in). The track is formed thru repeated cannulation at the same angle/depth each time (it's actually scar tissue purposely being formed). That's why it is preferable that buttonholes be cannulated by the same person every time, because they will more likely be able to remember which angle and depth to use. Otherwise, if different people cannulate the buttonholes and each person inserts the needle at a different angle/depth than the last person, they risk ruining the track/tunnel that was originally formed for the needles. Hopefully your mother's clinic has what they call a "cannulation expert" or someone experienced at establishing and cannulating buttonholes. My husband learned to cannulate himself. I merely help guide his hand. When he had to go to the hospital last year and needed dialysis, he was so out of it that he could not stick himself but since I'm the one who helps him do this every treatment, I remembered the angle and depth to put the needles in. A nurse at the hospital was going to stick his buttonhole but she had no idea what angle/depth to use and I was afraid that if I had let her do it, she would have ruined his buttonholes. Fortunately, she allowed me to stick the needles in and all went well. He still sticks himself but at least I know that if I have to, I can do it for him but only because I know what angle/depth he uses.

[jo]

Hopefully a new buttonhole will not need to be established. The vascular surgeon will be able to tell you if her fistula has good blood flow or not. As for the buttonholes, it's important that the needles be inserted at the same angle and depth each and every time to form a "track" inside (picture a small tunnel that the needle slides down in). The track is formed thru repeated cannulation at the same angle/depth each time (it's actually scar tissue purposely being formed). That's why it is preferable that buttonholes be cannulated by the same person every time, because they will more likely be able to remember which angle and depth to use. Otherwise, if different people cannulate the buttonholes and each person inserts the needle at a different angle/depth than the last person, they risk ruining the track/tunnel that was originally formed for the needles. Hopefully your mother's clinic has what they call a "cannulation expert" or someone experienced at establishing and cannulating buttonholes. My husband learned to cannulate himself. I merely help guide his hand. When he had to go to the hospital last year and needed dialysis, he was so out of it that he could not stick himself but since I'm the one who helps him do this every treatment, I remembered the angle and depth to put the needles in. A nurse at the hospital was going to stick his buttonhole but she had no idea what angle/depth to use and I was afraid that if I had let her do it, she would have ruined his buttonholes. Fortunately, she allowed me to stick the needles in and all went well. He still sticks himself but at least I know that if I have to, I can do it for him but only because I know what angle/depth he uses.

Yes, that's the problem at the center here. No one is trained enough to do the buttonholes and they pretty much experiment with my mom's fistula. New techs poke her everyday and it's not the same person every time. We are not sure what to do about this. I am thinking they had weakened the buttonhole by trying to poke at different angles and depth which could cause the bleeding? She didn't have bleeding during last session when she was poked by an experienced tech and everything went fine. But still, I am worried about how it's going to be tomorrow.

[Simon Dog]

because they will more likely be able to remember which angle and depth to use. Otherwise, if different people cannulate the buttonholes and each person inserts the needle at a different angle/depth than the last person, they risk ruining the track/tunnel that was originally formed for the needles.

I suspect this is why clinics use laddering and sharps except for the rare patient who self canulates.

The biggest surprise I had at home HD training was that the RN had me make my own buttonholes, and had me self-canulating from the 3rd day of training (I was too chicken to accept when she offered to let me do it on day 2 - took an extra day to work up my nerve).