Good lighting conditions, full gown and eye wear are strongly recommended. Like any other procedure in Emergency Medicine, it is important to have the patient appropriately monitored and with intravenous access be sure the patient is positioned in a manner that will allow you to stand and work comfortably, as this problem may take a good 30' to an hour to be resolved. Is this combination of a relative large puncture site, semi-arterial pressure in the vessel and the coagulopathy related to the patient (uremia, platelet dysfunction) and the dialysis circuit (heparinoids) that can make the management difficult. Fistulas are accessed using a 16-gauge or larger needles and heparinoids are used to prevent clotting in the circuit during the procedure. Typically the patient with PHSH will present with persistent bleeding from the access site on the AVF after their hemodialysis run despite direct pressure by healthcare staff. Life-threatening bleeding for an arteriovenous fistula (AVF) is a different clinical problem and frequently requires systemic hemostatic management including protamine and desmospressin and vascular surgery consultation, in this post we will focus on PHSH. Post-hemodialysis site hemorrhage (PHSH) is often encountered in the emergency department and although apparently a simple problem, sometimes can be quite difficult to stop and require a lot of time, effort and expertise to do so. Author: Cameron Wangsgard, MD and Daniel Cabrera, MD
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