Dialysis access complicationsMANAGEMENT

GENITOURINARY AND REPRODUCTIVE PRESENTATIONS · 12 SECTIONS

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587 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Acute Kidney Injury (ATN)Acute Kidney Injury (Post-renal)Acute Kidney Injury (Pre-renal)Amniotic Fluid Embolism Balanitis Bladder Rupture Breast Abscess Cystitis Dialysis access complications Ectopic pregnancy Epididymitis Glomerulonephritis Hematuria (gross)Hydrocele Interstitial Cystitis Mastitis Mittelschmerz Nephrolithiasis Nephrotic Syndrome Flare Nutcracker Syndrome Orchitis Ovarian Cyst Rupture Ovarian hyperstimulation syndrome Ovarian torsion Paraphimosis Pelvic Congestion Syndrome Pelvic Inflammatory Disease (PID)Peritoneal dialysis peritonitis Phimosis Priapism Prostatitis Pyelonephritis Renal laceration Renal transplant complications and rejection Ruptured ovarian cyst Testicular torsion Torsion of Appendix Testis Tubo-ovarian abscess Ureteral Rupture Urethritis Urinary Retention Urinary tract infection (uncomplicated)Urolithiasis (renal colic)Vaginal bleeding (non-pregnant)Vaginitis (Bacterial)Vaginitis (Candidal)Varicocele Vulvovaginal Hematoma

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp88

Immediate Threats

›Life threats

›Catastrophic access hemorrhage

›Pulsatile or high-volume bleeding from fistula, graft, or catheter exit site

›Hemorrhagic shock from unrecognized access rupture

›Herald bleed

›Small self-limited bleed preceding graft or fistula rupture

›Precedes catastrophic exsanguination, not an isolated benign event

›Mandates emergent vascular surgery evaluation, never discharge

›Airway compromise

›Expanding hematoma at neck for internal jugular catheter site

›Stridor or voice change from tracheal or vascular compression

›Septic shock from access infection

›Tunnelled catheter bacteremia most common source

›Hypotension, altered mental status, lactate elevation

›Limb-threatening ischemia

›Ischemic monomelic neuropathy

›Immediate severe pain, motor and sensory deficit within hours of access creation

›Emergency requiring urgent access ligation, not observation

›Severe steal syndrome with tissue loss

›Life-threatening hyperkalemia or fluid overload from missed dialysis

›Manage per Hyperkalemia and Acute Pulmonary Edema protocols

›Access-specific management detailed below in Treatment

Access Protection Rules

›Rules protecting the functioning access

›No blood pressure cuff on the access extremity

›External compression risks thrombosis

›Also produces an inaccurate reading

›No venipuncture, IV cannula placement, or routine blood draw in the access extremity

›Applies to fistula and graft limbs

›Exception is cannulation of the access itself by trained dialysis staff for its intended purpose

›Preserves future cannulation sites and avoids access injury

›A tunnelled dialysis catheter is not a routine access line

›Not for medications, fluids, or blood draws without explicit renal team involvement

›Reserved for dialysis therapy

›Breaking sterile lock technique introduces infection risk

›Label the access limb at bedside

›Wristband or signage to prevent inadvertent cuff or cannula placement by other staff

Routine ED Interventions Requiring Modification

›Iatrogenic harm checklist for the dialysis access patient

›Intubation

›Succinylcholine contraindicated if hyperkalemia suspected from missed dialysis

›Rocuronium preferred for rapid sequence intubation in this population

›Blood pressure cuff and IV access must avoid the access limb during setup

›Sedation

›Morphine active metabolite accumulates in renal failure — avoid

›Fentanyl or hydromorphone preferred, reduced starting dose

›Benzodiazepine metabolites also accumulate — titrate cautiously

›Fluid loading

›Anuric or oliguric patients tolerate little to no volume load

›Aggressive crystalloid boluses risk pulmonary edema

›Hypotension itself risks access thrombosis — treat cautiously rather than withholding all fluid

›Small aliquot trial with reassessment preferred over empiric large-volume bolus

›Oxygen

›Titrate to target rather than empiric high-flow

›Volume overload from missed dialysis can cause hypoxemia unresponsive to oxygen alone

›Vasopressors

›Norepinephrine reduces access blood flow and risks thrombosis

›Avoid administration through the access limb

›Use lowest effective dose when access flow preservation is a concern

›Mechanical circulatory support including intra-aortic balloon pump

›Requires femoral arterial access — avoid the limb bearing a lower-extremity dialysis access when present

›Coordinate site selection with vascular surgery when an access is present

›Anticoagulation

›Therapeutic anticoagulation converts access-site oozing into major hemorrhage

›Systemic anticoagulation is not routine empiric therapy for access thrombosis, unlike limb arterial occlusion

›Balance bleeding risk against other indications case by case

›Fibrinolysis

›Recently cannulated access site is a relative contraindication to systemic fibrinolysis

›Non-compressible or difficult-to-compress puncture site bleeding risk

›Catheter-directed thrombolysis for access thrombosis itself is a separate, targeted therapy

›Analgesia

›NSAIDs contraindicated — nephrotoxic and impair platelet function, worsening bleeding risk

›Opioid dose reduction and interval extension for renal clearance

›Acetaminophen 650 to 1000 mg PO or IV every 6 hours, maximum 3 g per day in chronic liver or renal impairment

Early Consultation Triggers

›Team activation

›Vascular surgery

›Herald bleed or catastrophic hemorrhage

›Suspected pseudoaneurysm with skin compromise

›Ischemic monomelic neuropathy or severe steal

›Interventional radiology

›Access thrombosis for pharmacomechanical thrombectomy

›Stenosis for angioplasty

›Central venous stenosis for venography and angioplasty

›Nephrology or renal team

›Every suspected access complication

›Missed dialysis with hyperkalemia or fluid overload

›Any decision to remove or salvage a catheter

›Infectious disease

›Persistent bacteremia beyond 72 hours

›Suspected endocarditis or septic emboli

02History/hx44

Access Characterization

›Access type and details

›Access type

›Arteriovenous fistula, native vessel

›Arteriovenous graft, synthetic conduit

›Tunnelled cuffed catheter

›Non-tunnelled temporary catheter

›Location and laterality

›Radial, brachial, or femoral inflow artery

›Internal jugular versus subclavian catheter site

›Access age and maturation status

›Fistula maturation typically 6 to 8 weeks before reliable cannulation

›Immature access more prone to thrombosis and cannulation injury

›Prior access interventions

›Prior angioplasty, stent, or thrombectomy

›Prior access abandonment or ligation

›Number of prior accesses — vessel exhaustion risk

Complication-Specific History

›Presenting complaint pattern

›Bleeding

›Onset relative to last dialysis session

›Spontaneous versus post-cannulation bleeding

›Prior similar bleeding episodes

›Pain, fever, or drainage at the site

›Purulent discharge

›Warmth or spreading erythema

›Decreased thrill or bruit noticed by patient or dialysis staff

›Difficulty cannulating at last session

03Physical Exam/exam45

General and Vital Signs

›Systemic assessment

›Hemodynamic stability

›Hypotension raising concern for hemorrhage or septic shock

›Tachycardia out of proportion to visible findings

›Fever

›Temperature at or above 38.0 degrees Celsius supports access infection or bacteremia

›Volume status assessment

›Jugular venous distension, crackles, peripheral edema for missed-dialysis fluid overload

Access-Specific Exam

›Access examination

›Thrill and bruit

›Palpable continuous thrill along the access, loudest near the arterial anastomosis

›Continuous low-pitched bruit on auscultation

›Loss of thrill or bruit indicates thrombosis until proven otherwise

›High-pitched or discontinuous bruit suggests stenosis

›Skin overlying the access

›Erythema, warmth, or fluctuance suggesting infection

›Purulent drainage from an exit or cannulation site

›Thinning, shiny, or ulcerated skin over a pulsatile mass — impending aneurysm or pseudoaneurysm rupture

›Spontaneous oozing over a pulsatile mass — herald bleed until proven otherwise

›Pulsatile mass characterization

›Size, tenderness, expansile quality

›True aneurysm — diffuse fusiform dilation of fistula wall

›Pseudoaneurysm — focal, usually graft-associated, contained by surrounding tissue rather than vessel wall

›Catheter exit site and tunnel

›Exit-site erythema and drainage

›Tenderness or induration along the subcutaneous tunnel track — tunnel infection

04Differential Diagnosis/ddx36

Access Dysfunction Differentials

›Complications by mechanism

›Thrombosis

›Absent thrill and bruit

›Sudden onset, often after hypotensive episode or excessive post-dialysis compression

›Stenosis

›Preserved but abnormal high-pitched bruit

›Rising dialysis venous pressures and recirculation preceding thrombosis

›Steal syndrome

›Distal ischemic symptoms with a patent, thrilling access

›Central venous stenosis

›Ipsilateral arm, neck, or facial swelling with a patent peripheral access

›Aneurysm or pseudoaneurysm

›Pulsatile mass, may or may not have overlying skin compromise

Infectious Differentials

›Access-associated infection

›Catheter-related bloodstream infection

›Fever with catheter in place, no other source

›Exit-site or tunnel infection without bacteremia

›Graft infection

›Localized erythema and tenderness, higher risk of anastomotic involvement

›Fistula cellulitis

›Superficial, native tissue more resistant than prosthetic material

›Metastatic seeding from access bacteremia

›Endocarditis

›Vertebral osteomyelitis or discitis

›Septic emboli

05Laboratory Tests/lt30

Infection Workup

›Culture strategy

›Blood cultures from the catheter, each lumen, and a separate peripheral vein

›Required to distinguish catheter-associated bacteremia from contamination

›Differential time to positivity supports catheter as the source when the catheter sample turns positive substantially earlier

›Blood cultures from a peripheral vein only for fistula or graft infection

›No catheter lumen to sample

›Culture of any purulent drainage or aspirated fluid

›Supporting labs

›Complete blood count

›Leukocytosis supporting infection

›C-reactive protein or erythrocyte sedimentation rate

›Adjunct for indolent graft infection, not diagnostic alone

Bleeding and Coagulation

›Bleeding workup

›Complete blood count

›Baseline hemoglobin and platelet count

›Serial hemoglobin if ongoing hemorrhage

›PT/INR and aPTT

›Anticoagulant effect assessment

›Type and screen

›Anticipate transfusion or surgical intervention for major hemorrhage

›Lactate

›Elevated with hemorrhagic shock or severe distal ischemia

Metabolic and Missed Dialysis Labs

›Renal and electrolyte panel

›Basic metabolic panel

›Potassium — critical if dialysis missed

06Diagnostic Tests/dt49

Scoring Systems

›Dialysis access-induced steal severity grading

›Stage I

›Cool or pale hand without pain

›Often an incidental finding on exam

›Stage II

›Pain or claudication with exercise or during dialysis

›Resolves with access flow reduction or between sessions

›Stage III

›Rest pain

›Present independent of dialysis or activity

›Stage IV

›Tissue loss — ulceration or gangrene

›Motor or sensory deficit

›Surgical revision or ligation indicated

MRI

›MR venography role

›Alternative for central venous stenosis mapping when iodinated contrast load must be minimized

›Gadolinium-based agents carry nephrogenic systemic fibrosis risk in severe renal impairment — use lowest-risk agent per radiology protocol

›Limited acute utility

›Longer acquisition time

›Not appropriate for the hemodynamically unstable patient

›CT venography

›Central venous stenosis or occlusion mapping

›Defines level and extent of obstruction

›Iodinated contrast tolerated in dialysis patients since renal function preservation is not a limiting factor

›Time contrast load administration with the dialysis schedule to manage transient volume load

07Disposition/dispo20

Admission Criteria

›Inpatient management indicated

›Catastrophic or ongoing hemorrhage

›Sepsis or hemodynamic instability from access infection

›Suspected tunnel or graft infection requiring surgical management

›Ischemic monomelic neuropathy or severe steal syndrome

›Missed dialysis with hyperkalemia or fluid overload requiring emergent dialysis

›Herald bleed or pseudoaneurysm with skin compromise pending vascular surgery

Transfer Criteria

›Escalation when local capability lacking

›No on-site vascular surgery for hemorrhage, aneurysm rupture risk, or steal emergencies

›No interventional radiology for urgent thrombectomy or angioplasty

›No dialysis capability for emergent hyperkalemia management

›Stabilize before transfer

›Direct pressure and hemostasis measures for bleeding

›Empiric antibiotics before transfer for suspected sepsis

›Direct communication with the receiving team

Specialist Consultation

›Uncomplicated stenosis or early thrombosis without limb or life threat

›Urgent outpatient interventional radiology or vascular surgery referral within days

›Not an emergent same-day requirement if the patient is otherwise stable and dialysis remains feasible via alternate access

›All other complications

›Emergent same-encounter consultation per Early Consultation Triggers above

08Treatment/t156

Bleeding Management

›Graduated hemostasis ladder

›Direct digital pressure

›Two-finger pressure directly over the puncture site

›Sufficient to stop bleeding but not fully occlusive of the underlying access

›Hold continuously for a minimum of 10 to 15 minutes before reassessing

›Topical hemostatic agents

›Topical thrombin applied to the bleeding surface under continued pressure

›Gelatin sponge dressing placed over the puncture site

›Suture closure

›Figure-of-eight or simple stitch across a puncture site that fails to tamponade with pressure and topical agents

›Lidocaine 1 percent local infiltration, maximum 4.5 mg/kg without epinephrine, prior to suturing

›Tourniquet — last resort only

›Proximal tourniquet to control catastrophic hemorrhage while awaiting vascular surgery

›Fully occludes the access and risks thrombosis and distal ischemia

›Bridge to emergent surgical control, not a definitive treatment

›Document application time and communicate immediately to the surgical team

›Herald bleed pathway

›Emergent vascular surgery consultation regardless of how minor the bleed appears

›Do not discharge a patient with a herald bleed

›Precedes catastrophic rupture, sometimes within hours

›Type and crossmatch in anticipation of major hemorrhage

›Avoid all further cannulation of the affected access

Infection Management

›Risk profile by access type

›Tunnelled catheter — highest infection risk of the three access types

›Biofilm formation on the catheter surface facilitates bacterial adherence

›Arteriovenous graft — intermediate risk

›Prosthetic material with higher risk of anastomotic involvement than native tissue

›Arteriovenous fistula — lowest risk

›Native tissue resists infection better than prosthetic or catheter material

›Empiric antibiotics — pending culture results

›Vancomycin for MRSA coverage

›20 mg/kg IV loading dose based on actual body weight

›Subsequent dosing guided by serum trough level or administered post-dialysis session per renal/pharmacy protocol

›Do not withhold MRSA coverage while awaiting the dialysis schedule

›Gram-negative coverage

›Cefepime 1 to 2 g IV, dosed for renal impairment and given post-dialysis when applicable

›Gentamicin 1 to 1.5 mg/kg IV as an alternative, dosed post-dialysis with level-guided redosing

›Narrow therapy once culture and sensitivity results available

›Cultures

›Paired samples from catheter hub or lumen and a separate peripheral vein

›Distinguishes catheter-associated bacteremia from contamination

›Peripheral cultures alone for fistula or graft infection without a catheter

›Catheter removal versus salvage

›Remove the catheter

›Tunnel or exit-site infection

›Hemodynamic instability or sepsis

›Persistent bacteremia beyond 72 hours of appropriate antibiotics

›Infection with Staphylococcus aureus, Pseudomonas species, or fungal organisms

›Evidence of metastatic infection — endocarditis, septic emboli, osteomyelitis

›Consider salvage with antibiotic lock therapy plus systemic antibiotics

›Uncomplicated bacteremia with a less virulent organism such as coagulase-negative staphylococci

›Clinical improvement within 48 to 72 hours

›No tunnel or exit-site infection

›Limited remaining vascular access sites favoring salvage attempt

›Nephrology involvement required for any removal or salvage decision

›Graft and fistula infection

›Graft infection typically requires partial or complete excision

›Especially with anastomotic involvement, given risk of mycotic pseudoaneurysm and hemorrhage

›Fistula infection managed with antibiotics and close surveillance

›Surgical excision reserved for abscess, necrosis, or failure to improve

Thrombosis Management

›Recognition and urgency

›Loss of palpable thrill and audible bruit defines thrombosis

›Not immediately limb-threatening in the way arterial limb ischemia is

›Salvage success declines as thrombus organizes and endothelializes over time

›Best outcomes with declotting attempted within 24 to 48 hours of thrombosis onset

›Later attempts up to several days may still succeed at a lower rate

›Who to call

›Interventional radiology — percutaneous pharmacomechanical thrombectomy, often first-line

›Vascular surgery — surgical thrombectomy with or without revision, or when percutaneous approach fails

›Local protocol determines primary operator

›ED management

›Do not attempt to manipulate, massage, or declot the access in the ED

›Systemic anticoagulation is not routine empiric therapy while awaiting thrombectomy

›Differs from arterial limb ischemia management

›Reserve anticoagulation for a separate independent indication

›Analgesia as needed

›Alternate vascular access or a temporary catheter arranged with nephrology if dialysis is due before salvage can occur

Stenosis Management

›Warning signs identified at dialysis

›Rising venous pressures during treatment

›Declining measured access blood flow on serial surveillance

›Prolonged bleeding after needle removal

›Bleeding lasting longer than 20 minutes after decannulation is abnormal

›Recirculation

›Venous-to-arterial needle recirculation from a downstream stenosis reduces effective dialysis clearance

›Detected by recirculation study or unexplained inadequate dialysis dose

›Difficulty with cannulation or new arm swelling

›Location

›Venous anastomosis in grafts

›Juxta-anastomotic segment in fistulas

›Both from neointimal hyperplasia driven by turbulent shear stress

›Management

›Balloon angioplasty first-line therapy

›Stent placement reserved for elastic recoil, recurrent stenosis within 3 months, or a surgically inaccessible lesion

›Urgent but not emergent referral unless thrombosis has occurred

Steal Syndrome and Ischemic Monomelic Neuropathy Management

›Steal syndrome management by stage

›Stage I

›Observation and reassurance

›Reassess at routine dialysis and follow-up

›Stage II

›Conservative measures with close monitoring

›Consider elective revision if symptoms progress

›Stage III and IV

›Urgent surgical revision required

›Banding to reduce access flow

›Distal revascularization-interval ligation procedure

›Revision using distal inflow procedure

›Access ligation as a last resort to preserve the limb when other revisions are not feasible

›Ischemic monomelic neuropathy — emergency not to miss

›Distinguish from classic steal

›Onset within hours of access creation or revision, not gradual

›Pulses and skin perfusion often preserved despite severe symptoms

›Pain and motor or sensory deficit are disproportionate to any visible ischemia

›Higher risk in patients with pre-existing peripheral neuropathy, particularly diabetics

›Immediate action

›Emergent vascular surgery consultation

›Urgent access ligation within hours to prevent permanent nerve injury

›Do not observe or defer — delay risks irreversible nerve damage

Aneurysm and Pseudoaneurysm Management

›Distinguishing features

›True aneurysm — fusiform dilation of all layers of the fistula wall

›Repeated same-site needle punctures or post-stenotic dilation

›Pseudoaneurysm — contained leak through the vessel or graft wall

›Usually graft-associated, contained by surrounding scar rather than vessel wall

›Skin changes predicting imminent rupture

›Thinning, shiny, or ulcerated skin overlying the mass

›Spontaneous oozing or bleeding

›Rapid enlargement on serial exam

›Loss of skin coverage or dusky discoloration

›Management

›Any impending-rupture skin change — emergent vascular surgery evaluation

›Immediate cessation of cannulation through the affected segment

›Stable aneurysm or pseudoaneurysm without skin compromise

›Outpatient vascular surgery referral for elective repair

›Continued cannulation elsewhere on the access if segment remains usable

Central Venous Stenosis Management

›Recognition

›Ipsilateral arm, neck, or facial swelling with a patent peripheral access

›Chest wall venous collaterals on exam

›Higher risk after prior subclavian catheterization than internal jugular catheterization

›Diagnosis

›Venography is the gold standard

›Duplex ultrasound of the peripheral access does not exclude central disease

›Management

›Angioplasty first-line for symptomatic central venous stenosis

›Stent placement for elastic recoil or recurrent stenosis

›Surgical bypass reserved for cases failing endovascular therapy

›Avoid subclavian vein catheterization for any future line placement in patients who may need future dialysis access

Missed Dialysis Presentation

›Recognition

›Confirm date and time of last dialysis session and number of sessions missed

›Assess for hyperkalemia and fluid overload symptoms and ECG changes

›Management

›Full hyperkalemia treatment per the Hyperkalemia protocol

›Full fluid overload and pulmonary edema treatment per the Acute Pulmonary Edema protocol

›Access-specific considerations

›Emergent dialysis uses the patient's existing fistula or graft, cannulated only by trained dialysis staff

›A new temporary catheter placed by trained personnel if the existing access is not usable or available

›The existing access is not for routine ED blood draws or fluids even during this presentation

›Early nephrology involvement to coordinate emergent dialysis timing and access use

09Special Populations/sp41

Pregnancy

›Pregnancy-specific considerations

›Imaging strategy

›Ultrasound first-line whenever adequate for the question

›Minimize iodinated contrast and ionizing radiation, proceed when access-threatening emergency outweighs risk

›Anticoagulation choice

›Heparin preferred, does not cross the placenta

›Avoid warfarin and direct oral anticoagulants

›Dialysis intensity

›Pregnant patients on maintenance hemodialysis often require increased session frequency, commonly five to six sessions weekly

›Increased access utilization raises complication risk during pregnancy

›Multidisciplinary coordination

›Nephrology, maternal-fetal medicine, and vascular surgery involvement for any access complication

›Fetal monitoring when a procedure or sedation is required at viable gestation

Geriatric

›Older adult considerations

›Vessel quality

›Atherosclerosis and vessel fragility increase catheter use and steal risk

›Higher rate of primary catheter placement when fistula creation is not feasible

›Bleeding risk

›Higher rates of anticoagulant use for atrial fibrillation increase access hemorrhage severity

›Atypical presentation

›Cognitive impairment may delay recognition of infection or thrombosis symptoms

›Reduced pain sensitivity can mask early steal syndrome

›Decision-making

›Frailty and functional status affect candidacy for revision versus ligation

›Goals of care discussion when repeated access failure limits further intervention options

10Background/b33

Epidemiology

›Population burden

›Roughly 500,000 patients receive maintenance hemodialysis in the United States

›Vascular access complications account for approximately 20 percent of hospitalizations among hemodialysis patients

›Roughly 80 percent of patients begin dialysis with a catheter rather than a mature fistula or graft, reflecting late nephrology referral

›Infection rates by access type

›Tunnelled catheter bacteremia incidence approximately 2.5 to 5.5 episodes per 1000 catheter-days

›Arteriovenous graft infection intermediate, roughly 0.5 to 2 episodes per 1000 access-days

›Arteriovenous fistula infection lowest, under 1 episode per 1000 access-days

›Steal syndrome and central stenosis rates

›Clinically significant steal syndrome requiring intervention occurs in roughly 1 to 8 percent of accesses overall

›Higher, up to approximately 20 percent, with proximal brachial artery-based accesses compared to distal radial-based accesses

›Central venous stenosis reported in up to approximately 40 percent of patients with prior subclavian catheterization, substantially lower after internal jugular catheterization only

Pathophysiology

›Mechanisms

›Neointimal hyperplasia

›Turbulent flow and shear stress at the venous anastomosis or juxta-anastomotic segment drive stenosis

›Arterial steal

›Low-resistance arteriovenous shunt diverts arterial flow away from the distal capillary bed

›Catheter-related infection

›Biofilm formation on the catheter surface facilitates bacterial adherence and impairs antibiotic penetration and host clearance

›Aneurysm and pseudoaneurysm formation

›Repeated needle trauma to a focal segment without adequate healing interval weakens the wall

›Same-site area or buttonhole cannulation increases risk compared to rope-ladder site rotation

›Central venous stenosis

›Catheter-induced endothelial injury and fibrosis, most pronounced with subclavian vein catheterization

Therapeutic Considerations

›Guiding principles

11Patient Discharge Instructions/pdi24

copy discharge instructions

›Home care instructions

›Bleeding at home

›Apply firm direct pressure over the puncture site continuously for 10 to 15 minutes without checking

›If bleeding continues beyond 20 minutes of continuous pressure, return to the emergency department immediately

›Access protection at home

›No blood pressure cuff, blood draws, or IV placement in the access arm

›No heavy lifting or sleeping with pressure on the access arm

›Check the thrill by feeling for a buzzing sensation over the access at least once daily

›Fever and infection precautions

›Temperature at or above 38.0 degrees Celsius (100.4 degrees Fahrenheit) — call the dialysis unit or return immediately

›New redness, swelling, warmth, or drainage at the access site

›Dialysis schedule

›Attend every scheduled dialysis session

›If a session is missed or cannot be attended, call the dialysis unit the same day

›Return immediately for

›Any bleeding not controlled with 20 minutes of continuous pressure

›Loss of the buzzing sensation (thrill) over the access

›Fever at or above 38.0 degrees Celsius

›New arm pain, numbness, weakness, or coolness

›New or worsening arm, neck, or facial swelling

›Missed dialysis with weakness, palpitations, shortness of breath, or leg swelling

›Follow up

›Dialysis unit and nephrology at the next scheduled session

›Vascular surgery or interventional radiology follow up within 1 to 2 weeks if a complication was identified but not requiring same-day intervention

12References/r21

Guidelines and Key Sources

›Primary guidelines

›National Kidney Foundation KDOQI 2019 Clinical Practice Guideline for Vascular Access

›Update to the original 2006 KDOQI vascular access guideline

›Individualized access selection and fistula-first principles with surveillance recommendations

›IDSA Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection

›Mermel LA et al.

›Catheter salvage versus removal criteria and empiric antibiotic selection

›Society for Vascular Surgery Clinical Practice Guidelines for arteriovenous hemodialysis access

›Surgical placement, surveillance, and revision recommendations

›Key trials and initiatives

›Dember LM et al. Effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis. Dialysis Access Consortium trial. JAMA 2008

›Antiplatelet therapy to reduce early fistula thrombosis, did not improve ultimate maturation

›Fistula First National Vascular Access Improvement Initiative

›National quality initiative driving increased fistula prevalence over catheter and graft use

Coding References

›ICD-10 references

›N18.6 end stage renal disease

›Z99.2 dependence on renal dialysis

›Z49.01 encounter for fitting and adjustment of extracorporeal dialysis catheter

›I77.0 arteriovenous fistula, acquired

›T82.7 infection and inflammatory reaction due to other cardiac and vascular devices, implants, and grafts

›T82 complications of cardiac and vascular prosthetic devices, implants, and grafts — parent code family for mechanical complications, subdivide by device and complication type per current coding reference

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed September 13, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.