Case Report: IV access in a dialysis patient: An Evidence free zone!

So the below is only my opinion! We are definitely in an evidence free zone and this is not meant to guide management! However this is my nightmare. 

A 53 yo ESRD is BIB EMS to a small community hospital. Her chief complaint: missed dialysis. She reports staying at her NH and not having been picked up for dialysis for the past week. She is on HD, Tues, thurs, and Saturday. Her last IHD was a week ago and her most recent one was unable to be continued because her graft had clotted off. She does not feel short of breath but does note her body is more swollen. SHe has no other symptoms. Past medical history includes (but not limited to): DM, HTN, ESRD on HD, and a right sided CVA with deficit on the right side. On exam her BP is 224/112, HR is 78, RR 20 (as usual), and afebrile. On exam she is in no acute distress and non-toxic appearing, she is morbidly obese, she speaks in full sentences, she has keloid formation on both sides of her neck and anterior chest wall. She has a moderate contracture on the right arm from her prior CVA, she has a Arteriorvenous graft (AVG) on the left arm with no palpable thrill or bruit. She further has bilateral above the knee amputations. Bilateral radial vessels are palpable no other findings. The nurses are unable to find a vein on the arm with the CVA and tell you they cannot do an IV on her arm with the graft. The lab tech is unable to obtain a blood draw given her skin changes and lack of venous access.  You are asked to obtain blood and you do so by radial arterial draw. Her ECG shows no peaked T waves and her Potassium (K) is 6.8.

So, to sum up this is a 53 yo female on dialysis with a clotted graft, no accessible veins peripherally by 2 different nursing attempts and the charge RN, no accessible EJ on the neck (visually or by US) due to keloid, no accessible mammary veins on the chest due to b/l keloid, no legs, an AV graft on the left arm and the right arm is fixed ADducted and held in flexion and cannot be straightened due to the stroke.

What do you do? Where and How do you get IV access? Do you put in a central line? If so where?

WELCOME TO MY NIGHTMARE AND A COMPLETELY EVIDENCE FREE ZONE!!!!

Where do we start?

As far as IV access goes, we are all aware that we “shouldn’t” use the arm with the AV graft (AVG) or fistula (AVF). But when we NEED blood and IV access as in the above case where do we start? Let’s look at this.

There are slim to none guidelines in this area. The only semblance of guidelines is from the 2006 KDOQI (Kidney Disease Outcomes Quality Initiative, http://www.KDOQI.org). In the section on “Clinical Practice Guidelines for vascular access”, pg 340 states “1.1 The veins of the dorsum of the hand should be the preferred site for IV cannulation.” And  under patient preparation for permanent access states “ In patients with CKD stage 4 or 5 forearm and upper-arm veins suitable for placement of vascular access should not be used for venipuncture or placement of IV catheters, subclavian catheters, or PICCs)

Does this mean both hands? Does this mean after or before placement of the AV access. No one will ever know…

The rationale for these recommendations are for PRESERVATION of the veins to create an AV fistula or graft, and maximize chances or successful fistula placement and maturation. Furthermore it is for prevention of thrombosis. These are the reasons for the PIV cautions. They report the incidence of central vein stenosis and occlusion after upper extremity placement of PICC and venous ports is 7% in 1 retrospective series of patients. PICCs are also associated with an incidence of upper extremity  varies between 11% and 85%. Thus PICCs should not be used in CKD.

And that sums up all the recommendations!

At kidney.org, the housing site for the KDOQI guidelines, there is a post that states:

“Post date: February 10, 2014

I have permitted peripheral IV access in the back of the hand on the same side as the AV fistula. I do not permit IV access above the wrist on the same side as the fistula. I do not permit Peripherally Inserted Central venous Catheters (PICC) access to be placed in any dialysis patient with a fistula. I only permit centrally lines in the Right Internal Jugular position. The KDOQI guidelines recommend right sided central venous catheters, avoiding subclavian catheters and avoiding peripheral IV access in any dialysis patient or pre-dialysis patient. They also mention using the back of the hand veins for peripheral access but avoiding the arm veins for peripheral IV access.”

Obviously not high quality data…

The nurses were unable to obtain IV access or blood from either hand or veins on the chest wall.

Next step for me was to look for an EJ… sadly, no luck too much keloid formation over both sides of the neck nor could I find distended EJ’s visually  or by ultrasound.  Because of the left arm contracture and her soft tissue edema I had a very difficult time finding a deep brachial vein. In my own personal experience I feel the basilic vein is more likely to infiltrate whether you happen to “back wall” the vessel or not. However, after getting more help positioning the patient and have a few people hold her I was able to get a peripherally inserted 20 ga 1.88” (48mm) Angio catheter in the most anterior deep brachial at the level of the mid bicep. Now to find a new pair of underwear!

If that failed, I guess I would have done a right IJ since her graft is on her left arm and guidelines say to avoid Subclavian vessels. Also theoretically, an IO of the right humerus could be done emergently but being a renal patient I’m sure her bone strength is minimal.

So in summary, obtaining IV access in an HD patient would be in the following order:

  1. Dorsal veins in the hand
  2. Peripheral on the contralateral AVF/AVG side
  3. External Jugular (either
  4. IJ contralateral to the AVF/AVG; if CKD 3-5 then Right IJ preferred but either is Ok
  5. If PICC is needed substitute in a tunneled EJ/IJ catheter by IR

Avoid

  1. Above the wrist on the AVF/AVG side
  2. Subclavian central line
  3. PICC

In case you were wondering what the steps are for accessing a fistula I found this wonderful article, by Manning, on how to do that:

Any gauge and type of needle may be used, although a large-bore (14, 16, or 18 gauge) needle is recommended in emergency circumstances. A needle is preferable to an angiocatheter because it is easier to secure with tape under the high pressure of the fistula. A tourniquet should be used when cannulating an AV fistula and removed immediately after cannulation. The tourniquet should be placed in the axilla area and applied lightly. These precautions will help prevent thrombosis, the most common cause of AV fistula and AV graft failure. One should scrub the skin at the puncture site with povidone-iodine, allow the skin to dry, and follow with a scrub using isopropyl alcohol.  The needle should be inserted into the AV fistula at an angle of 20 to 35 degrees until a flashback of blood is noted (The angle should be increased to 45 degrees if the nurse is cannulating an AV graft.) After the flashback, insert the needle up to 0.32 cm (1/8 inch) further and decrease the angle until the needle is flat with the skin. The needle or catheter should be advanced to the hub to prevent bleeding around the insertion site. If using an intravenous catheter, one should be prepared to attach intravenous or saline lock tubing quickly to avoid unnecessary blood loss. Blood flowing through the AV fistula travels at a high velocity, so fluids need to be infused under pressure. One must take care to tape the needle or catheter to the skin securely in a chevron fashion to prevent dislodging.

If the fistula has been accessed in the previous 24 hours and the needle puncture sites are visible, the nurse should take care to access the fistula at least 2.5 cm (1 inch), either proximal or distal, from the previous site to allow healing time and to avoid the formation of an aneurysm. Prior to and after cannulation, the emergency nurse should assess the AV fistula for a thrill and document its presence. The AV fistula can be de-accessed in the same manner as a peripheral intravenous line, with pressure applied after the needle or catheter has been removed. The nurse should take care to hold gentle, nonocclusive pressure for a full 10 minutes at the insertion site.

References:

  1. Manning, M. Use of dialysis access in emergent situations.J Emerg Nurs 2008;34:37-40. Available online 18 October 2007. doi: 10.1016/j.jen.2007.03.018. PMID: 18237665
  2. https://www.kidney.org/blog/ask-doctor/what-recommendation-peripheral-iv-placement-dialysis-patients-avf-and-avg-i-am
  3. February 2012 ASN kidney news. The PICC conundrum: Vein preservation and Venous Access. https://www.kidneynews.org/kidney-news/special-sections/interventional-nephrology/the-picc-conundrum-vein-preservation-and-venous-access

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