What are the risks of using a tourniquet to control a fistula bleed?

Risks of Using a Tourniquet to Control a Fistula Bleed

Tourniquets should not be used to control fistula bleeding due to significant risks of nerve damage, limb ischemia, and potential vascular access damage, with direct pressure being the recommended first-line approach. 1

Primary Risks of Tourniquet Use on Fistulas

• Tourniquets can cause temporary or permanent injury to underlying nerves and muscles when applied to control bleeding 1
• Systemic complications may develop from limb ischemia, including acidemia, hyperkalemia, arrhythmias, shock, and in severe cases, death 1
• Complications are directly related to tourniquet pressure and duration of occlusion 1
• Nerve palsy has been identified as the most prevalent complication associated with prolonged tourniquet use 2
• Post-tourniquet syndrome and increased thromboembolic event risks can occur with prolonged application 2
• Using a tourniquet on a fistula may damage the vascular access itself, potentially compromising future dialysis treatments 1

Recommended Approach for Fistula Bleeding Control

First-Line Management

• Direct pressure is the recommended first-line approach for controlling bleeding, including fistula bleeds 1
• Apply firm manual pressure on gauze placed over the bleeding source until bleeding stops 1
• The amount of pressure applied and duration are the most important factors affecting successful control of bleeding 1
• If bleeding continues, do not remove the gauze; add more gauze on top and apply more pressure 1

Second-Line Options

• If continuous manual pressure cannot be maintained, wrap an elastic bandage firmly over gauze to hold it in place with pressure 1
• Local cold therapy (such as an ice pack) can be useful for extremity bleeding control 1

When Tourniquets Might Be Considered

• Tourniquets should only be used if direct pressure is not effective or possible 1
• They should be considered only for life-threatening bleeding that cannot be controlled by other means 1
• Specifically designed tourniquets are better than improvised ones 1
• Proper training is essential before applying a tourniquet 1

Important Precautions If Tourniquet Must Be Used

• Note the exact time of tourniquet application and communicate this to medical personnel 1
• Some guidelines suggest a maximum application time of two hours 3
• Military reports document cases where tourniquets remained in place for up to six hours with extremity survival, but this should not be considered standard practice 1
• If a tourniquet must be used, it should be removed as soon as possible to minimize tissue damage 4, 3
• Assessment of bleeding should occur every 2 hours if the tourniquet cannot be removed sooner 3
• If bleeding has stopped, the tourniquet should be replaced with a pressure bandage 3

Special Considerations for Fistula Access

• A fistula that only works with a tourniquet in place is likely underdeveloped, usually due to inflow stenosis, and needs more time or reevaluation before use 1
• Applying a tourniquet to a fistula for bleeding control risks damaging the access itself, which could lead to access failure 1
• For dialysis patients with fistula bleeding, direct pressure should always be the first intervention, with tourniquets reserved only for life-threatening hemorrhage that cannot be controlled by other means 1

Conclusion

The evidence strongly indicates that tourniquets should be avoided for fistula bleeding control unless absolutely necessary in life-threatening situations where direct pressure has failed. The risks of nerve damage, limb ischemia, and damage to the vascular access itself outweigh the benefits in most clinical scenarios.