Dialysis blow outs: what, how, why and what to do

Belinda emailed me last week asking about her blown fistula. It thought the response could be valuable information to anyone who has just started the BigD.

Belinda:

I just started Dialysis one week ago, this being my second week. Today something went wrong and blood was everywhere and my arm was so swollen they had to cut me out of my sweater. The nurse tech said maybe I had a clot my arm is black and blue and hurts, hopefully, it will heal before I go back Monday. My question is how do you know if it’s your arm or if it was the fault of the tech? And what do you do, because I don’t want to make someone angry at a place i have to go to three times a week.

Here’s my response:

Hi Belinda, I’m very sorry to hear about your arm. I and pretty well every other BigD member know exactly how you feel. At least you are not alone. What’s happened is called “blowing” your fistula. It happens when the needle (which is very sharp) pushes right through the fistula wall so that the blood from the machine pumps directly into the flesh and muscle around your fistula. Blow outs are painful, they are dramatically ugly and the extensive bruising lasts a few weeks until your body dissipates the blood (and mental anguish and irritation).

Unfortunately, blow outs can be common in the early days in the life of a fistula, because the fistula walls are very soft and new. Even a small arm movement or inserting the needle a little too vigorously during cannulation will do it.

As for who is at fault, no one does it deliberately. If it happened before you went on the machine, it may have occurred during cannulation, though as I said, it is especially tough to get the needles right during the first few weeks of dialysis. If it happened during the run, it may be that you moved your arm just a bit too much, and inadvertently pushed the needle through the fistula wall. As you say, you will be there three times a week for quite a while, so put it down to experience (unless it happens regularly, then it’s time for another unit).

The good news is that as your fistula gets older, the walls get tougher, you get more savvy, and it is less likely to happen. Have a look at my posts on getting the needles in, so that you know what’s happening inside the fistula and how to avoid blows in the future.

Also, from what you say, it was a few minutes before anyone noticed that it had blown. From your part, that is simply lack of experience (who knows what is normal during the first few weeks?). Unfortunately, if the dialysis staff are not nearby at the time, the blowout can be quite severe before they take action (which is why you need to be able to recognise one early and let them know ASAP).

How to recognise that your fistula has blown and what to do

Either needle can have a blow out, but the effect is dramatically different depending on which one blows.

If the arterial needle (the one closest to your wrist, supplying the blood to the machine) blows, the machine will alarm quite quickly: this is because the needle is no longer in the fistula, the blood supply slows dramatically, the machine sucks harder and this extra negative pressure sets off sensors in the machine. Some blood will seep from the fistula hole into your arm, but not much. Applying pressure to the blow area for about 5 minutes limits the damage, which will be barely noticeable a day or two later. This is the least common blow out.

If the venous needle (the one further up your arm, delivering the cleaned blood from the machine back into you) blows, things can be a little more dramatic. The machine takes a few minutes to alarm because it is happily pumping blood into all that empty space next to the fistula. It takes a while to “fill up” that area until the back pressure sets off sensors that stop the machine pumping. The resulting overflow of blood into your arm can be painful, distressing and the resulting bruise takes weeks to gradually disappear.

What can you do to minimise the blow out?

Firstly, be aware of how your arm feels during normal dialysis. If something changes in how it feels, it may have blown: a short stabbing pain (where the needle has gone through the fistula wall) is a good indicator. Unfortunately, you often can’t feel the blood going into your arm until there is a lot there.

Secondly, keep an eye on how your arm looks during dialysis: if it starts to swell, it has probably blown.

If you think it has blown, act quickly: clamp off the venous supply line, either with the in-line clamp or an arterial clamp; failing that, just clamp or knot the line with your free hand like you would a garden hose. The machine will sense the increased pressure and stop pumping. Then call out for help, press the nurse call button, etc.

Your nurse will remove the needle and re-cannulate in a different location, to resume the dialysis, or to return the blood in the lines to you and end your run early, depending on how long you have been dialysing.

I’m sorry to say that there’s not much you can do to reduce the impact of a blow out. You will get an almighty bruise which will be sore for a while. Many people recommend Hirudoid or a similar bruise reduction cream, but I haven’t found it to be particularly effective. As I said, the chance of blow outs reduce as you become more experienced, but they still happen (I had one about 3 months ago).

The only plus is they look amazing: flash your arm or photos of it to impress relatives, induce shock and awe in strangers or scare small children.

Better still, keep vigilant and keep your good looks.

28 thoughts on “Dialysis blow outs: what, how, why and what to do

  1. Hi Greg, and gang it’s me again your annoying neigborhood dialysis nurse, just in response to the post I reccommend applying ice in the first 24 hours after a blow of course hyrodid cream is fine, but remember it is a heparinsed cream it will reduce clotting and therefore bruising but it must never be used staright after dialysis it should only be used on non dialysis days if you use it straight after a blow it will increase bleeding and therefore bruising.

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    • Hi Coby, thanks for your comment (you are not annoying, but most welcome!). I didn’t know not to apply Heparin for 24 hrs, which is maybe why I am unimpressed with it. I will give it a try when and if (hopefully not) I need it again.

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  2. Hi Greg…just catching up with your latest posts…I am sure you helped Belinda…I found that so informative…no doubt you realise that the Kidney Foundation would benefit from your articulate accounts and positive feedback…the more that know this info the better…M

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  3. Hi All,
    I am the caregiver of a Big D patient. Your advice and explanation to Melinda were great. I wish my husband and I had seen this when he first started in Oct.2009. He is still new to dialysis and I get quite upset knowing how much pain and discomfort he experiences weekly. My advice to Belinda is keep your eyes open, the staff is not always focusing on you. They have no idea what you feel and I’m not sure many of them care. At least this is how theya re at my husband’s treatment center.
    Try to remain positive and God Bless.

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  4. Hi again all, I just wanted to leave a response in reply to Sharon, dialysis nurses are rare and a special breed ask any long term dialysis patient, we do care.
    Nurses who blow a patient’s arm often feel more upset then the patient. I have known them to cry, throw up and even faint. I know I have cried I feel terriable when I inflict pain on a patient. We are aware that a patients fistula is their lifeline and we don’t want to do anything to jepordise that, but we are also human. So like Sharon said rightly or wrongly sometimes we do have other things on our minds, sometimes we are tired, sometimes we are just having an off day. None of this helps the patient of course, but nurses are human too and we make mistakes. We have the best intentions though. We might for a time slip into self doubt and avoid difficult fistulas but eventually we have to get on with it.
    But remember out there patient needling is all about confidence if you have any resevations about a nurse who has had trouble in the past keep it to yourself. If we lose confidence then we can’t do our job. I always tell my patient if they don’t give up on me I will never give up on them. I always put in 100% effort, and 99% of the time things work perfectly. Then there are blow outs which reduce to me to tears and make me question why I am doing the job I love so much, but then the patient moves on and so do I.
    Stay postitive.

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    • Thanks for another great comment Coby. It’s encouraging to know what it feels like at the other end of the needle! Not that we doubted it.
      Greg

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  5. hi my names maya from new zealand. my dad passed away 1 years ago aged 44. he had been on dialysis for about two years. he had been complaining about his sore and swollen fistular for months but nothing was done. my mum woke up next to him to discover him dead, he had put pressure on it and it burst as he did not feel it he bleed to death. his autopsy showed all his body organs were 100% healthy apart from his kidneys. we are angered by his treatment, resulting in his death. nothing has been done even though a full investigation was meant to take place. could you please give me some advice on what i can do, how i can bring this to the attention of others that might do something, and is this very common? i would appreciate any feed back. thank you…maya cassidy

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    • Hi Maya. What a terrible story! I am so sorry to hear about your father’s death and I can barely imagine what it must have been like for your mother and you.

      I have taken some time before responding, mainly because I needed to think about what happened and how to react.

      Firstly, no, this is not common. I have spoken about it with several people with years of dialysis experience and a senior Dialysis Unit Manager thought that your father “May have developed an aneurysm (a dilation of the fistula caused by a weakening of the fistula wall), with repeated puncturing, which thins the wall and develops scarring and it may have well burst; it can happen anytime and anywhere. I have only seen one burst fistula from an infection in 30-plus years but he was in hospital so we managed to save him”.

      Also, I have known blood to flow (sometimes quite fast) from the needle holes if the dressings have been removed before the wound has closed. This is especially the case if the person is on a blood thinning drug (like Warfarin), that slows blood clotting. This can happen regardless of the state of the fistula.

      But then your father complaining of a sore fistula should have rung all sorts of alarm bells. It could have been anything from infection to a clot or major blockage. If this was the case, your father’s dialysis unit, his care nurse, his doctor or clinic and the hospital may well have some explaining to do. Anything going wrong with a fistula can be life-threatening.

      Without knowing more about your father’s situation, it is hard to understand how it could have happened. Did the autopsy provide an explanation? Or is the matter still with the coroner? Sometimes it can take a couple of years to get an official answer.

      With regard to what to do, I think the best way to bring this to the attention of the people that matter is firstly to talk to or email the NZ Health and Disability Commissioner. The Commissioner is independent of any hospital or other body, so you can usually be sure that you will get both a prompt response and action. The start the process, go to Making a Complaint . You can begin by discussing your father’s death with Health and Disability Consumer Advocate, or Raise a Complaint immediately.

      In both cases request a detailed report. You need to have it clearly explained what happened with a Nephrologist and Vascular Surgeon. Help is available to get things started. I would be surprised if you don’t get an immediate response.

      But if you are unhappy with the response, there are several other courses of action: you could contact your local MP – Contact an MP, or an opposition MP, or email your story to the national newspapers, the Dominion Post in Wellington – News (or Phone 0800 DOMPOST), or the NZ Herald Contact News Staff.

      Please feel free to ask for help or support at any time. Let me know what happens, and particularly what and why it happened, once you know more.

      I look forward to hearing from you,
      Greg

      ps: Maya, I think this is a very important story, so I have reproduced your post and my reply as this week’s post. Greg. Updated 21 Feb 10

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    • Hi Maya, This message finds you a few years late. I know exactly what you are talking about as I have experienced the same. I was very lucky as I was awake when it happened and the paramedics arrived in time to save me it was a close call for me. My heart hurts for you for there is nothing that can prepare you for that and the dialysis centers will never mention the risk factors. My story will be posted later.

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  6. Hey everyone im 15 and new to dialisis I started in august 2010 and progressing all right i think.
    they recently tried my fistula and it didnt blow (*TouchWood*) But it spasismed Which was quite painful

    Im having my Neck Line out next weds as its falling out and the cuff is 3cm away from my nipple Lol
    anyways bye for now

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  7. Hi, I dont know if my fistula is alright, It has blown up on my arm. It is large in diameter. and it works great but it bothers me seeing how much is pops up now. I have been on horrible dialysis for a year and two months. I butt heads with a few people, I worry about everything. Could the fistula get too big and explode? Thank you in advance for you response. If you could sent that response to lamedorsoh@hotmail.com

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    • Hi Lisa. It depends on how swollen your fistula is. If it is thin and easily punctured, or sore or infected, there may be potential for it to rupture under pressure. The largest part of mine is fairly large – about 10cm (4 in) long and about 1 cm (1/2 in) high- but is strong and stops bleeding quickly. The best thing to do is to ask your dialysis team or even better, your doctor or specialist. Greg

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      • Thanks for the response, I can not learn enough about the dialysis issue. My fistula is maybe 3 inches,not sure how high, maybe 1/2 inch as yours. My fistula runs good and stops bleeding quickly as well. The doctor wants me to have a fistula gram, he has not looked at ,it just has been a year since my last one. I am sick of all this crap and having to worry about all the dialysis problem, watching what food I eat, I have sharko foot, which my bones in my foot are disinigrating. I go to what feels like a million billion doctors. I hate all this, I hate it, I hate it, I hate it.

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  8. tks for alot of information from yr article. i am Lilian from penang, malaysia. i have just started my 1st dialysis two days ago. and i am now having extensive bruises from the two cannulation site(though not swollen after some warm compress, but the bruises stay for 2 days already and not yet disappear. very worry now to go for second dialysis!

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  9. Hi! My name is Nicole and I have been on dialysis since 1983 and I just wanted to share that my venous needle just blew 30 minutes ago!! It hasn’t happened to me for about 25 years! I panicked and felt really anxious. This was the first web page I found and I will say I felt calmer after reading this post. So don’t stress, even us long termers have their moment!! Great site by the way – I will be sharing it with my outreach nurse and my specialist!

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  10. In my own experience there are two types of blow outs. The first is your fistula blow out, this is when your needle becomes dislodged and breaks thru the vein or artery. Very Painful, lots of bruising, and swelling.
    Then you have the more severe blow out and that is the access total failure. Usually due to scabs on the access. When this happens, you hope and pray that there is someone close at hand to help. Otherwise, pray the paramedics will arrive in time, because you are bleeding out. The uncontrollable pressure. blood squirting out everywhere. The lose of blood is so great and so fast the patent has but minutes to survive. The lose of blood is so severe that the patent soon starts to lose consciousness.
    The only chance for survival is an emergency vascular surgery to negate the access (tie it off completely). If the patent survives then they must get transfused (2, 3, 4 or more units of blood). There is nothing that can prepare you for this type of blow out. Although not painful in any way, the sheer panic is overwhelming. The emergency surgery was very painful. no Anastasia, no litacane knowing that the emergency room team are working in a timely manner to save the patents life.
    I thank God for another day and the team of medical staff in the ER that night.

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    • Hi Bertha. Certainly do not carry heavy stuff (more than a kg/a couple of pounds) immediately after dialysis or for the rest of the day. However, the next day should be fine, as long as your fistula is healthy. I often go to the gym the next day and lift weights (bicep curls 7-6kg/15lb each arm) without any fistula problems. I don’t usually try to pick up things that are really heavy (where I have to strain hard). Laying on your arm: I try to not lay on my arm. Regards, Greg

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  11. I had a blowout about a week ago on my fistula. It happened before I went on the machine, and it was the top one that blew (the one where the clean blood enters). I’m in a lot of pain with my left arm, I can’t move it any further than a 90 degree angle and the middle of my arm still feels very heavy and very very sensitive. I’ve told the nurses on numerous occasions that my arm isn’t getting any better. Is there any stretches or anything that I can do, to help stimulate the arm into straightening?

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    • Hi Trish. Your fistula does not sound right. The blood should flow freely through with no pain when you bend your arm or otherwise move it. It may have a blockage, where the blood clots and stops or restricts the flow, especially during dialysis. Ask you unit supervisor for a fistulagram, where a vascular surgeon looks at the fistula from the inside and clears out blockages, etc. Don’t let them put you off.

      I’m not aware of any exercises that can help stretch or otherwise reshape your fistula. However the surgeon can expand narrow bits from the inside (using a balloon) during the fistulagram.
      Keep in touch. Greg

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  12. Pingback: Dialysis: death via a damaged fistula | Big D and Me

  13. My father is 81 and is on dialysis since June 2016. So far everything was going well except for the last 3 visits where in it was either difficult to get the needle right or even if they put the needle correctly after 2 hours of dialysis the blood flow stops. We were told that there is block in the vein and it can’t be removed. So they are going to start neck line again and make fistula on the right arm. Why the blockage is happening and why it can’t be removed. I am worried now if something happens to the right arm also what will they do?

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    • Hi Revathi. Now and then, fistulas can block up and can’t be repaired, either because the vein walls are too weak, or the remaining part of the vein area is unsuitable (maybe it’s too scarred, won’t expand to create a new fistula, etc.). Then the vascular surgeon looks for a new place to create a new fistula. Typically, they look at the other arm; in your father’s case, his right arm. Hopefully, it will form quickly and if treated well by dialysis staff, will not block up. He will need the neck line to keep dialysing while the fistula forms. In the highly unlikely case that the new fistula fails, there are still options, like grafts and even a fistula in the upper leg. But hopefully, all will be well with his new right arm fistula.

      Good luck and let us know how things go. Regards, Greg

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    • Hi Wanda. Blood going into the flesh of your arm can be ugly and painful (like a bruise – it is a bruise!), but not dangerous. It gradually dissolves over a week or two. You can sometimes make it disappear more quickly if you use something like Hirudoid cream (around A$15), which penetrates the skin to heal bruises quickly. I have very thin skin, so it is not so effective for me, but it may help you. Good luck! Greg

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  14. This happened to me, the first Dialasis treatment. My arm looked like it was double in size. They squeezed out a lot blood. It is still is very swolen, and most of my arm is bruised. Quite embarrasing, and scary!

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  15. Luv the response. I recently had my 2-year-old fistula blown. It created an ugly bruise, along with soreness. I’ve been keeping ice packs on it and it’s not getting better but worse. Talked with my dialysis nurse she recommended a trip to the ER to make sure it’s not infected or something bad.

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