1. AVF Haemorrhage Presentation - prepared by Pauline Byrne
Heed the Herald Bleed: An Ominous Warning for Potential Vascular Access Rupture
Prepared by
Pauline Byrne CNS Vascular Access Coordinator Renal Centre, Wollongong, ISHLD
Wollongong Hospital 2011

2. Heed the Herald Bleed……… and ACT!!
Clinical Excellence Commission (CEC), RCA of fatal bleed from an AV fistula (IIMS)
Review of similar events:  identified five other deaths and nine significant incidents.
2011: a further death as result of bleeding from an AV fistula
The CEC asked ACI for advice on prevention and education resources.
This PowerPoint was developed to assist with staff training
as part of a package of resources aimed at staff, patients and carers.
Remember: Heed the Herald Bleed! ACT! Save a life!

3. Objectives of this Presentation :
AVF Haemorrhage Presentation - prepared by Pauline Byrne
Objectives of this Presentation :
To define a ‘Herald Bleed’ & potential outcome
To assess Access Functionality & identify ‘Vascular Access at Risk’
Outline one centre’s ‘Acute Management Plan’
Describe the role of stakeholders in management of access at risk
To demonstrate through a case study review: recognition and management of an access at risk of rupture.
Wollongong Hospital 2011

4. What is a : ‘Herald Bleed’
AVF Haemorrhage Presentation - prepared by Pauline Byrne
What is a : ‘Herald Bleed’
Definition: ‘Herald’ - an indication of something that is going to happen
In relation to either an Arterio-Venous Fistula (AVF) or Arterio-Venous Graft (AVG), a herald bleed refers to either a small or large spontaneous haemorrhage.
A herald bleed may lead to potential vascular access rupture and loss of life.
In preparation for this presentation, a literature review was conducted to examine case reports , reviews and current guidelines in management of vascular access complications.
Whilst this search did yield information on how to assess performance, function and management of complications such as stenosis, aneurysms and infections , no literature was discovered when employing the key words of ‘ herald ‘’ , ‘ & bleed’* with haemodialysis vascular access. Widening the search by using alternate key words such as ‘’rupture’, ‘only produced two case reports ,in which one referred to the surgical management of an aneurysmic fistulae that had ruptured., whilst the other did discuss through case review the possible causes of spontaneous rupture such as infection, but no mention to the term ‘Herald Bleed’.
In view of this , and from our local experience, I have associated the following meanings to the terms of a ‘Herald Bleed”.
Wollongong Hospital 2011

5. AVF Haemorrhage Presentation - prepared by Pauline Byrne
Introducing Mrs.Q
Mrs. Q- 68 yrs old, ESRD- secondary to Wegener’s Granulomatosis
PTFE Loop inserted Right thigh-24/09/2007
Presented ED 2 years post- insertion –afebrile, chills, and graft red and painful.
Blood Culture/Treated IV Antibiotics
Day 7-Abscess over graft/blister like appearance, spontaneous bleed in a Satellite unit on dialysis.
Wollongong Hospital 2011

6. How Can We Identify Access at Risk ?
AVF Haemorrhage Presentation - prepared by Pauline Byrne
How Can We Identify Access at Risk ?
Look- Visual Inspection
Feel-Palpate Thrill and Pulse
Listen- Character of Bruit
Observe- Access re Pressure Trends during Haemodialysis Treatment.
Wollongong Hospital 2011

7. AVF Haemorrhage Presentation - prepared by Pauline Byrne
Visual Inspection:
Examine Skin Integrity -
Is skin thinning over access sites?
Is infection present?
Is Infection present with sudden appearance aneurysmal dilatation?
Visual inspection of both autogenous fistulae and grafts is key in evaluating access at
risk,.
An early manifestation of graft infection according to Bachleda et al in their review of infectipous complcations associated with e PTFE Grafts in 2010,was bleeding from the anastomosis. Clinical findings such as warmth,redness ,oedema,serous or purulaent secretion from the wound leads to a diagnosis of infection, with a tunnel infection cited as extremely serious.
Wollongong Hospital 2011

8. AVF Haemorrhage Presentation - prepared by Pauline Byrne
Visual Inspection:
Examine Skin Integrity
Presence of Scabs/Blebs
Exposed e PTFE Graft
Development of blisters and black scabs indicate both poor wound healing and skin integrity. Obtaining a history from the patient may reveal that the fistulae has had episodes of spontaneous bleeding .
Degeneration of an AVG due to repeated punctures combined with necrosis of the overlying tissue can result in bleeding from cannulation sites,sever haemmorrhage and graft rupture.
An e PTFE graft that is placed in to shallow position,with repeated punctures can cause the skin to become eroded , resulting in exposure . Exposure of e PTFE is potentially serious, as exposure of actual puncture holes will lead to haemmorrhage and by definition is infected.(Dialysis Access and Recirculation-Toros Kapoian et al
Wollongong Hospital 2011

9. Degraded PTFE graft: ‘One-site-itis”
AVF Haemorrhage Presentation - prepared by Pauline Byrne
Degraded PTFE graft: ‘One-site-itis”
Wollongong Hospital 2011

10. AVF Haemorrhage Presentation - prepared by Pauline Byrne
Visual Inspection:
Is access limb oedematous?
If an upper limb access -the presence of collateral veins, and over chest may indicate central venous stenosis
Is there facial oedema same side as access?
Wollongong Hospital 2011

11. AVF Haemorrhage Presentation - prepared by Pauline Byrne
Visual Inspection:
Development or increase in size of Aneurysmal/Pseudoaneurysmal Dilatations ?
Clinical practice guidelines published by kdoqi , advise that progressive enlargement of an aneurysm can compromise the skin above the fistulae, leading to possible rupture,resulting in haemmorrhage exsangunation and death. In patients for whom the skin layer within the aneurysm is thin and prone to infection is a sign of impending perforation.
Wollongong Hospital 2011

12. Aneurysms & Pseudoaneurysms
AVF Haemorrhage Presentation - prepared by Pauline Byrne
Aneurysms & Pseudoaneurysms
Aneurysm formation in primary fistulae can be due to–
Stenosis
cannulation technique- such as area puncture
Area puncture technique can cause:
thinning of the skin at puncture sites
Bleeding along needles
Longer bleeding time post-dialysis
Pseudoaneurysms are caused by-
degeneration of graft material combined with venous outflow stenosis
If Pseudoaneurysms have-
rapid expansion in size exceeding twice the diameter of the graft + viability of the overlying skin threatened ‘ Are at risk of Rupture’  Requires Vascular Review
Aneurysm formation in primary fistulae can be as a result of stenosis or due to cannulation technique such as area puncture. Current published guidelines on vascular access advise against this technique and according to McCann et al in an overview on vascular access managment, an area puncture techniquecauses not only aneurysm formation but thinning of the skin at pucture sites,bleeding along the needles and longer bleeding time after cannulae removal,.
The degeneration of an AVG combined with a venous outflow stenosis fosters formation of a pseudoaneurysm., which if characterised by rapid expansion in size, exceeding twice the diameter of the graft, and where the viability of the overlying skin is threatened ,are at risk of rupture, and therefore surgical correction is indicated.
Wollongong Hospital 2011

13. Why You should not cannulate into Aneurysms & Pseudoaneurysms........
AVF Haemorrhage Presentation - prepared by Pauline Byrne
Why You should not cannulate into Aneurysms & Pseudoaneurysms
Aneurysms
Pseudoaneurysms
Aneurysms as they enlarge
compromise the overlying
skin of the fistula, and for those patients where skin layer is thin and prone to infection, is a sign of impending perforation.
There is no vessel nor graft in dilated wall- only skin + subcutaneous tissue.
Wollongong Hospital 2011

14. Assessing Functionality: Why palpate and auscultate access?
AVF Haemorrhage Presentation - prepared by Pauline Byrne
Assessing Functionality: Why palpate and auscultate access?
*Indicators for identifying stenosis*
Palpation
The ‘Thrill’-at the anastomosis- should be prominent and continuous, with the pulse soft and compressible.
If stenosis –thrill may only be present in systole, the pulse may be increased and have a ‘water-hammer character’
Auscultation-The bruit should be continuous and low pitch.
If stenosis- the character of the bruit changes to a high pitch & discontinuous.
Wollongong Hospital 2011

15. Assessing Functionality: What Other Observations are Useful?
AVF Haemorrhage Presentation - prepared by Pauline Byrne
Assessing Functionality: What Other Observations are Useful?
Resistance on cannulation
Can indicate stenosis + if clotting = possible impending thrombosis
Measuring Trends in Venous & Arterial Pressures.
Venous Pressure- trend upwards can indicate venous stenosis
Arterial Pressure- below -150/-250 may indicate inflow stenosis
Observe Bleeding time post-dialysis
Post-Dialysis: Prolonged bleeding may indicate proximal stenosis
Wollongong Hospital 2011

16. Diagnostic Confirmation of Access at Risk:
AVF Haemorrhage Presentation - prepared by Pauline Byrne
Diagnostic Confirmation of Access at Risk:
Formal Duplex Assessment: a non-invasive method of evaluating: arterial & venous stenoses, graft thrombosis, infection, aneurysm, pseudoaneurysm formation and arterial steal.
Access Flow Measurement:
Risk of Access Failure: Fistula flow < 500 mls/min Graft < 600 mls/min.
Trends and setting of individual thresholds advised.
If a stenosis is suspected this according to KDOQI & EBPG should be confirmed by objective measurements such as ultrasonography,angiography and access flow measurements.
Wollongong Hospital 2011

17. One Unit’s Action Plan If Access suspected at risk of Rupture:
AVF Haemorrhage Presentation - prepared by Pauline Byrne
One Unit’s Action Plan If Access suspected at risk of Rupture:
Suspected infected fistulae/grafts, identified herald bleed, evident black scab or blebs, sudden onset aneurysmal dilatation, exposed e PTFE grafts:
Do not cannulate:- Renal Registrar/Vascular Registrar review
If infection- septic screen / IV Antibiotics
Exposed e PTFE-treat as infection
Admission
Formal Duplex study of access
Vascular Revision if clinically required
Wollongong Hospital 2011

18. AVF Haemorrhage Presentation - prepared by Pauline Byrne
Case Study : Mrs Q
Mrs. Q- 68 yrs old, ESRD- secondary to Wegeners Granulomatosis
24/09/2007: PTFE Loop inserted Right thigh
Presented ED 2 years post- insertion: afebrile/chills/graft red & painful.
Blood Culture/Treated IV Antibiotics
Day 7: Abscess over graft/blister like appearance; spontaneous bleed in a satellite unit on dialysis.
Vascular review: formal U/S, IV Antibiotics
31/07/2009: ’small spurt’
‘Blister ruptured - small opening’
31/07/2009: Revision - new PTFE tunnelled, old loop excised.
Graft cultured-MRSA
IV Antibiotics: Vancomyocin x 6 weeks
Wollongong Hospital 2011

19. Ongoing Management- Targeting Education to Stakeholders
AVF Haemorrhage Presentation - prepared by Pauline Byrne
Ongoing Management- Targeting Education to Stakeholders
Patients & Carers: to recognise and inform medical & nursing staff of abnormalities noted with their vascular access, have knowledge of what to do in an emergency.
Nursing Staff: to recognise a vascular access at risk & report to medical staff, provide & review education to patients on a regular basis, provide patients with a ’Bleeding Emergency Kit’
Resident Medical Officers/Medical Registrars: to recognise the normal attributes of vascular access with high blood flows, to recognise what defines a vascular access at risk, and implement treatment plan as per local policy guidelines
In NSW ,the Agency for Clinical Innovation has appointed a group of health professionals led by Professor Maureen Lonergan with also the presence of a consumer advocate to develop education strategies in identification and management of fistulae and grafts at risk of rupture.
Wollongong Hospital 2011

20. Poster: “Heed the Herald Bleed”

21. What Can Your Unit Achieve?
AVF Haemorrhage Presentation - prepared by Pauline Byrne
What Can Your Unit Achieve?
Wollongong Hospital 2011

22. In Summary This Presentation has:
AVF Haemorrhage Presentation - prepared by Pauline Byrne
In Summary This Presentation has:
Defined a herald bleed as ‘ ...spontaneous small or large haemorrhage from an AVF/AVG’
Described: how to assess functionality of an AVF/AVG & to identify types of vascular access at-risk of rupture
Outlined both an acute management plan, and a teaching strategy for relevant stakeholders
Demonstrated through a patient case study: the detection of an access at risk with subsequent medical and surgical management.
Wollongong Hospital 2011

23. AVF Haemorrhage Presentation - prepared by Pauline Byrne
References:
Bachleda et al.,2010,’Infectious Complications of Arteriovenous
e PTFE Grafts for Haemodialysis’, Biomedical Papers of the Medical
Faculty of Polacky University in Olomouc,Czech Republic,pp.13-19
Caksen et al., 2003, ‘Spontaneous Rupture of Arteriovenous
Fistula in a Chronic Dialysis Patient’, The Journal of Emergency Medicine,pp
GOOGLE IMAGES
Kapoian et al., Dialysis Access and Recirculation, Chapter
5,pp.1-14, 5.
Mc Cann et Al.,2008,’Vascular Access Management 1:An Overview’, Journal of Renal Care,pp.77-84
Mc Cann et Al.,2009, ‘Vascular Access Management II:AVF/AVG Cannulation Techniques and Complications’, Journal of Renal Care, pp.90-98
Wollongong Hospital 2011

24. AVF Haemorrhage Presentation - prepared by Pauline Byrne
References (cont.):
National Kidney Foundation-KDOQI –Clinical Practice Guidelines for Vascular Access Update 2000,
Tordoir et al.,2007 ‘European Best Practice Guidelines on Vascular Access’, Nephrology, Dialysis and Transplant Journal.pp
Tricht et AL., 2005,’Haemodynamics and Complications Encountered with Arteriovenous Fistulas and Grafts as Vascular Access for Haemodialysis: A Review', The Annals of Biomedical Engineering pp
Yan et al.,2009, ’Successful surgical treatment of a ruoture to an arteriovenous fistula aneurysm’, ‘Cardiovascular Journal of Africa’, pp
Wollongong Hospital 2011

25. AVF Haemorrhage Presentation - prepared by Pauline Byrne
Acknowledgements:
Professor Maureen Lonergan
Director Renal Services, Illawarra and Shoalhaven Area
Dr Kohlhagen, Dr Holt, Dr Greenstein, Dr Wen and Dr Zafiriou
Nephrologists, Wollongong Renal Centre
Dr Huber, Dr Villalba and Dr Stanton
Vascular Surgeons, Wollongong
Dialysis Staff
Wollongong/Shellharbour/Shoalhaven
Mrs. Q
Case Notes
Wollongong Hospital 2011