Advanced Practice: Dialysis Fistula Bleeding

Why Fistulas Bleed?

  • Frequent puncture to access fistula with 16G or larger needle
  • Uremic platelet dysfunction
  • Supra-therapeutic anticoagulation with heparin
  • Fistula abnormalities (pseudoaneurysm, stenosis, infections)
  • Semi-arterial pressure so can bleed a lot


  • Usual ABC’s + resuscitation, obtain IV access
  • Direct pressure is 1st line for 10-15 minutes
    • Gentle pressure as excessive direct pressure can lead to iatrogenic fistula thrombosis
    • Can also provide pressure proximal and distal to fistula to avoid direct pressure
    • If resolution → observe in ED x 2 hours for re-bleeding and US to assess for AV fistula complications
  • Can try topical hemostatic agents like gelfoam or recombinant thrombin but often need a dry area for those to work
  • Consider protamine as heparin often used to prevent clotting → 1 mg of protamine for every 100U heparin used during dialysis
  • IV DDAVP has been shown to decrease bleeding time in patients with uremic platelet dysfunction → 0.3 mcg/kg IV over 10 minutes → contraindicated in hyponatremia, CHF
  •  If above measures fail:
    • Consult vascular
    • Consult nephrology as well
    • If pt is very unstable and at risk of dying → tourniquet or excessive direct manual pressure → patient at risk for limb ischemia and fistula thrombosis.
  • +/- figure of 8 stitch → some ED providers do this but others advice discussing in consultation with vascular surgery and nephrology as access is patient’s life line