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Fistulas and peripheral IVs

This is an e-mail I sent to the nephrologists at our hospital. I amy get better answers here;o) thanks        

               We are looking for some expert guidance for our practice and procedure of placing and maintaining peripheral IV access in our CRF patients with active and non-functioning HD fistulas. We recognize preservation of functioning fistulas is of paramount importance to these folks. We would not place an IV in a functional fistula arm unless a life threatening emergency (cardiac arrest). Occasionally, we get patients with a failed fistula arm and a functional fistula arm. In the past, we required an order from nephrologists to use the non-functional fistula arm. Currently, our procedure reads, " Unless life threatening emergency, with no alternative access, extremities with functioning or non-functioning A/V fistulas and lymph node dissection/lymph edema are NOT to be used for IV insertion." This is even more restrictive.

    Our question is to the risk of complications and the appropriateness in using non-functioning fistula arms for peripheral IV access. Obtaining an order from nephrology at 2am to place an IV seems tedious and unnecessary. It is either OK or it is not, right? The "Fistula First" guidelines instruct, "Do use the dorsum of the hand of the non-access arm for venipuncture and IV infusions". I assume that means in the presence or absence of a non-functioning fistula or graft. Is this a reasonable allowance, and an absolute restriction of the rest of the arm? What is the best next step? PICC lines and anything subclavian is out of the question with the risk of thrombus formation, correct?
    Any depth of information, opinion, and suggestion is much appreciated.