A-V Fistula access

[TakayaSue]

I was wondering just how sacred those A-V fistulas are in ESRD-HD patients. We had a patient go into asystole 3 times yesterday, s/p HD and they insisted on putting in femoral lines to administer fluid and ACLS drugs. Unfortunately, when she got the to MICU it turned out that both lines were placed in the femoral arteries, which begs the question -- why not just put a 14-gauge peripheral catheter in the A-V fistula and give anything you want via that? It seems silly to save it for HD -- I would think that once you are intubated and getting full-court-press ACLS that all bets would be off, and that if you make it vascular surgery can pick up the pieces later.

Does anyone have any evidence/experience/expert opinion one way or the other on this matter?

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[drewpydog]

Agreed. If you are dead, you are dead - use the dialysis fistula to stave off Darwin. Luckily, I don't have many of those type folks where I practice now. We used the fistulas on ESRD codes in residency. Don't forget the EJs though - usually people on dialysis have huge ones.

 

[txterp98]

I've accessed them in codes during residency and as an attending.

A senior resident told me when I was an intern something to the like of: I'd rather access it and give them a chance than have them die with a pristine AV graft.

Made sense to me.

 

[roja]

I have never accessed one before. However, we use U/S for our femoral lines. They are not pristinely sterile in code situations but our u/s machine is in our resusc room and always on, so I just slap the probe on. Doesn't take any longer....

 

[emtcsmith]

I hate to twist the subject but does anyone have access or use EZ-IO in the ED setting instead of using a fistula or or taking time to establish a central line?

 

[BADMD]

I hate to twist the subject but does anyone have access or use EZ-IO in the ED setting instead of using a fistula or or taking time to establish a central line?

Having been forced to place an IO in a patient that had zero accessible veins, I can say that they stink as a resuscitation line. There is no way that I would choose to place one when I had a healthy looking fistula that I can access.

 

[lucky_deadman]

The only reason I can think of to not use the fistula is if the cause of the arrest is something that's gonna need dialysed out as soon as a pulse returns.

 

[spyderdoc]

I've accessed the dialysis cenral lines before in critical patients, but haven't had to access any fistulas or shunts yet. I surely would not hesitate to if I couldn't get access elsewhere.

 

[EctopicFetus]

I've accessed the dialysis cenral lines before in critical patients, but haven't had to access any fistulas or shunts yet. I surely would not hesitate to if I couldn't get access elsewhere.

Agreed. I usually make sure these people have good access as long as it isnt a code situation.

EF

 

[matt_mt19]

Have placed a few of the "EZ-IO's," which for those of you who don't know the IO needle is essentially just attached to a drill which allows very quick and efficient insertion. I have used them when the coding patient had no access and I wanted to at least have a smidgen of access while throwing in a central line somewhere, with that being said they actually worked really well.

As far as the fistula goes, if the patient is coding I'd put a needle in that fistula before I would the tibia... but that's just my 2 cents.

 

[docB]

We have them at a few places. Just to make it more complicated we have the EZ IO at one place and the BIG at another. I have tried to avoid using them because I just have to pull it out and replace it later on. In my community hospitals none of the admitting docs will put in a central line so we get called up to the floor to do it. Very painful. I can usually get a femoral in in under 2 min.

 

[WakeDoc]

as an aside, I think the messiest medical code I have ever seen involved a fistula that literally exploded. It was weird to call for trauma blood and the Level I infuser for a medical code...I don't know why it exploded, but a little intradialysis Heparin and a huge hole in your artery will make for some wild times. She rolled in EMS as hypotensive and nearly dead. We couldn't get the bleeding stopped....there were some other very gory details that will remain undisclosed.

 

[Dr.Evil1]

Agreed. If you are dead, you are dead - use the dialysis fistula to stave off Darwin. Luckily, I don't have many of those type folks where I practice now. We used the fistulas on ESRD codes in residency. Don't forget the EJs though - usually people on dialysis have huge ones.

You must not practice where I do. Sometimes I wonder how blood actually gets back to the heart at all in some of my patients. BADMD and I had the worst vascular access code ever a while back and the IO attempts went poorly. In adults so much of the marrow in the distal extremities has been replaced with bone that the distal tibia isn't the greatest spot for access.

 

[deleted109597]

If they need emergent dialysis afterwards, a 19.5 cm Quinton cath will work just fine. However, you could always simply put in a femoral introducer just as easily, so the difference is negligible.

Where I am, nephrology refuses to let someone die until they receive dialysis. If they could hook a kidney up to the CVVH, they would.

 

[docB]

You must not practice where I do. Sometimes I wonder how blood actually gets back to the heart at all in some of my patients. BADMD and I had the worst vascular access code ever a while back and the IO attempts went poorly. In adults so much of the marrow in the distal extremities has been replaced with bone that the distal tibia isn't the greatest spot for access.

I have to agree. I just had a code last night where EMS had placed b/l tibial IOs via EZ IO and neither worked. Of note they placed those to avoid using the Quentin she had in her chest.