48-year-old female patient, HTN CKD STAGE 5D, was on thrice a week MHD, through left BC AVF. One day she had venous needle dislodgement due to an unintentional limb moment. This led to excessive bleeding which was timely detected and stopped by the dialysis technician. Here we can see the oozing of blood from the needle end and AVF puncture site and dialysis technician is compressing needle puncture site.
DISCUSSION
VND (Venous needle dislodgement) is when the venous needle in AV fistula or AV graft falls out while an ABLS (Access bloodline separation) is when the dialysis catheter or fistula needle becomes disconnected from the haemodialysis blood circuit whilst the patient is on dialysis therapy.
It is a rare but life-threatening complication of dialysis therapy.
Venous needle dislodgement can happen if the needle is pulled out or not taped correctly. If the venous needle comes out of your arm during dialysis, blood will spurt very fast from the fistula and blood circuit. The dialysis machine will continue to remove your blood (through the arterial needle) but will be unable to return the blood to your body. If an arterial needle comes out, it will lead to air in the blood circuit. Sometimes the whole dialysis catheter comes out due to suture issues and that can lead to bleeding from the insertion site of the dialysis catheter and also from the catheter tip as still blood circuit is attached with dialysis catheter.
On the other side access bloodline separation is due to separation of access from blood circuit due to improper tightening of connection between access and blood circuit.
VND and ABLS are one of the most challenging safety monitoring problems for haemodialysis patients. Venous pressures typically exhibit minimal changes with disconnection, and life-threatening blood loss can happen, often within a few minutes.
The major factors leading to needle dislodgement and access bloodline separation are
Access related factors
- Faulty technique used for needle fixation and bloodline securement
- Loose luer lock tubing connection
- Bloodlines not being looped loosely
- Difficult cannulation due to access location, angle of cannulation
Patient factors
- A restless, confused, agitated, or uncooperative patient pulling the needle out of the access
- Patients who experience treatment complications: Hypotension, muscle cramps or diaphoresis. Patients experiencing muscle cramping often have excessive movement while trying to find relief, which can result in needle dislodgement. Hypotension can cause excessive sweating, resulting in tape loosening from the skin.
- Blankets obscuring an access
- Tape becomes adhered to the blanket or loosened with movement
- Unintentional limb movement
Dialysis unit/staff related factors
- Inadequate patient observation by staff
- Alarm fatigue, which is the syndrome of overriding the alarm without a thorough assessment of the cause of the alarm, also increases the risk.
- Patients dialyzing at home, patients dialyzing in isolation area, nocturnal dialysis
MANAGEMENT OF NEEDLE DISLODGEMENT OR ACCESS BLOOD LINE SEPARATION
Stop the blood pump urgently.
Puncture site to be compressed with gauge peace urgently.
If having needle dislodgement, remaining needle to be used to return blood.
Normal Saline to be infused from the detached end of the blood circuit to return blood.
Check blood pressure and haemoglobin and may need blood transfusion but as packed cell volume takes some time for availability at a moment bolus Normal Saline can be given if hypotension.
With needle dislodgement, if pending dialysis to be completed then another needle to be interested at a separate place with utmost care for hematoma formation as patient would be heparinized. Better to avoid heparin infusion now considering a new needle is inserted and the previous puncture site is still not healed.
If a patient is HIV, HbsAg or HCV positive special care to be taken to clear contamination of surfaces.
If both needles are removed we can insert Vigo and infuse blood slowly to prevent blood loss.
Need to check CBC report before next dialysis as immediate CBC report may not show fall in haemoglobin. And at that time blood transfusion may be needed.
Article Courtesy – Dr. Jigar Shrimali
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