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Heed the Herald Bleed: An Ominous Warning for Potential Vascular Access Rupture. Prepared by Pauline Byrne CNS Vascular Access Coordinator Renal Centre, Wollongong, ISHLD. Heed the Herald Bleed……… and ACT!!.

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Heed the herald bleed an ominous warning for potential vascular access rupture

Heed the Herald Bleed: An Ominous Warning for Potential Vascular Access Rupture

Prepared by

Pauline Byrne CNSVascular Access CoordinatorRenal Centre, Wollongong, ISHLD

Heed the herald bleed and act
Heed the Herald Bleed……… and ACT!!

  • Clinical Excellence Commission (CEC), 2010 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!

Objectives of this presentation
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.

What is a herald bleed
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.

Introducing mrs q
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.

How can we identify access at risk
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.

Visual inspection
Visual Inspection:

Examine Skin Integrity -

  • Is skin thinning over access sites?

  • Is infection present?

  • Is Infection present with sudden appearance aneurysmal dilatation?

Visual inspection1
Visual Inspection:

  • Examine Skin Integrity

    • Presence of Scabs/Blebs

    • Exposed e PTFE Graft

Visual inspection2
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?

Visual inspection3
Visual Inspection:

  • Development or increase in size of Aneurysmal/Pseudoaneurysmal Dilatations ?

Aneurysms pseudoaneurysms
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

Why you should not cannulate into aneurysms pseudoaneurysms



Why You should not cannulate into 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.

Assessing functionality why palpate and auscultate access
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.

Assessing functionality what other observations are useful
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

Diagnostic confirmation of access at risk
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.

One unit s action plan if access suspected at risk of rupture
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

Case study mrs q
Case Study : Mrs Q

  • Mrs. Q- 68 yrs old, ESRD-secondary to WegenersGranulomatosis

  • 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

Ongoing management targeting education to stakeholders
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

Poster heed the herald bleed
Poster:“Heed the Herald Bleed”

In summary this presentation has
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.


  • 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.224-225


  • Kapoian et al., Dialysis Access and Recirculation, Chapter

    5,pp.1-14,www.kidneyatlas.org/book 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

References cont
References (cont.):

  • National Kidney Foundation-KDOQI –Clinical Practice Guidelines for Vascular Access Update 2000,www.kidney.org/professionals/kdoqi/guidelines

  • Tordoir et al.,2007 ‘European Best Practice Guidelines on Vascular Access’, Nephrology, Dialysis and Transplant Journal.pp.88-117

  • 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.1142-1156

  • Yan et al.,2009, ’Successful surgical treatment of a ruoture to an arteriovenous fistula aneurysm’, ‘Cardiovascular Journal of Africa’, pp.186-197.


  • 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


  • Mrs. Q

    Case Notes