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Joan Lemock
AV fistula use for routine IV access

Has anyone ever used a native AV fistula for routine access and IV antibiotic infusion?

Went round and round regarding a patient yesterday and today with history of renal transplant so functioning fistula isn't being used for dialysis. Patient needs at least 4 weeks IV antibiotic tx for infected hip prosthesis then surgery to replace. Went to OR yesterday for tunneled cath but surgeon unable so he placed an IJ TLC that was looped caudally onto itself and therefore useless (removed postop). Vascular surgeon recommends using AV fistula which ID doc, attending and myself disagree with. Patient had PICC that developed thrombus in other arm - we evaluated for possible PICC in arm with AV fistula but no acceptable veins present.  I have an awesome team and we are going to try to maintain peripheral access through the weekend but know long term peripheral is not realistic. So options are very limited!  Anybody have any thoughts or recommendations on the AV fistula usage?  I know this is not appropriate but has anyone ever seen it done?  Thanks    

Wendy Erickson RN
To my knowledge, this is

To my knowledge, this is NEVER done except in an emergency.  The risk of hemorrhage is huge if the needle (even a peripheral IV) falls out.  There is so much pressure in a fistula.  And just to clarify, you are talking about placing the needle into one of the enlarged vessels from the fistula, not directing INTO the fistula itself, right?  Didn't want anyone to misunderstand.  Four weeks is a long time to try to maintain this - would the patient remain inpatient?  I definitely would not send someone home with this, even to a nursing home.  What about a port in an IJ?  Just becasue the TLC looped wouldn't necessarily mean that a new line would do the same thing, would it?

The nephrologists definitely need to be involved in this decision!

Wendy Erickson RN
Eau Claire WI

Joan Lemock
Wendy thanks for your

Wendy thanks for your feedback. Your concerns validate everything I have shared with the physicians and nursing leadership team. This patient absolutely could not be discharged from acute care and 4 weeks (minimally) is a long time with many substantial risks associated with doing this. Patient also has PT and I'm majorly concerned with risk for hemorrhage anywhere this patient would be located if not under constant observation.  We have NEVER done anything like this and it goes against every infusion standard of care I've known (in my 31 years as a nurse, mostly as an advanced practice infusion specialist).  We are advocating for another attempt; this time for implanted medport placement by another surgeon. Thank you again for validating.

That would definitely be

That would definitely be uncomventional, although I have heard of articles on this very subject.   I would not refer this patient to a surgeon.  He needs to go to IR where they can evaluate the central veins if there is an occlusion.  They can do other creative things to obtain access.  Our IR department is now tunneling power piccs in the IJ exiting on the chest for short term access on dialysis patients.  This has worked great for us.  We are looking into the small bore tunneled lines. 


Good luck,

D. Cole, CRNI


Darilyn Cole, RN, CRNI, VA-BC
PICC Team Mercy General Hospital Sacramento, CA


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