Fatal Dialysis Vascular Access Hemorrhage

Area of Science:

• Nephrology
• Vascular Surgery

Background:

• Bleeding from dialysis vascular access (arteriovenous fistulas, arteriovenous grafts, vascular catheters) is an uncommon complication.
• Deaths from such bleeds are rare, with incident rates below 1 per 1,000 patient-years, suggesting units may see such an event only once a decade.

Purpose of the Study:

• To review reported deaths from vascular access bleeding in Australia and New Zealand over 14 years.
• To identify lessons learned and opportunities for prevention of these rare but catastrophic events.

Main Methods:

• Retrospective review of all reported deaths due to vascular access bleeding.
• Analysis of individual dialysis units' root cause analyses for each event.

Main Results:

• Vascular access bleeding deaths are infrequent but catastrophic.
• Data from Australia and New Zealand over 14 years were analyzed.

Conclusions:

• Death from dialysis vascular access hemorrhage is uncommon but potentially preventable.
• Implementing appropriate policies and procedures is crucial for preventing these rare bleeding deaths.