Hemorrhage
Risk Factors
- Platelet dysfunction
- Ineffective platelet-vessel wall interaction and heparin induced thrombocytopenia (HIT)
- Use of anti-coagulation during HD
- Co-morbid conditions
- Uncontrolled hypertension
- Liver disease, sepsis, certain medication (especially anti-platelet drugs )
- Access site kept covered
- Venous needle falling out or catheter connection disrupted (venous pressure may fall too little to cause an alarm)
Risk Assessment1
- Very high – Active bleeding during HD
- High – Surgical/traumatic wound within 3 days
- Low – Surgical/traumatic wound > 7 days
Diagnosis and Treatment
- Screen for bleeding and activated clotting time
- Prolonged bleeding time – cryoprecipitate, DDAVP or conjugated estrogen acutely
- Prolonged PTT (heparin induced) – Protamine, FFP
Prevention
- Should never keep access site covered
- Review heparin dose
- Strategy based on risk assessment1,2
- Low risk – low dose conventional heparin, low molecular weight heparin
- Very high/high risk – regional anticoagulation with heparin and protamine, heparin- free dialysis, regional citrate anticoagulation, Prostaglandin (PGI2), PD
Alternative Methods to Conventional Heparin for High-Risk Patients
Methods | Problems |
Heparin-free dialysis | Rebound |
Regional heparinization with protamine reversal | anticoagulant, bleeding |
Low dose heparin | Clotting of dialyzer |
Low molecular weight heparin | Bleeding |
Prostacyclin | Flushing and hypotension |
Regional citrate anticoagulation | Complex technique, metabolic acidosis and hypocalcemia |
References:
- Swartz RD, Port FK. Preventing hemorrhage in high-risk hemodialysis: Regional versus low-dose heparin. Kidney Int 16:513-518, 1979
- The EBPG Expert Group on Haemodialysis. Chronic intermittent haemodialysis and prevention of clotting in the extra corporal system. Nephrol Dial Transplant 17:S63-S71, 2002