Will Placing an IO on the Same Arm as a Fistula Ruin the Fistula?
No, placing an intraosseous (IO) device on the same arm as an arteriovenous fistula will not directly "ruin" the fistula itself, but it violates fundamental vascular access protection principles and should be absolutely avoided. The arm with a fistula or graft must be protected from any invasive procedures including IO placement, blood draws, IV lines, and blood pressure measurements due to risks of infection, thrombosis, and damage to the arteriovenous access 1.
Why the Fistula Arm Must Be Protected
Core Principle of Fistula Preservation
- Any blood draws, infusions, and blood pressure measurements are contraindicated in the AVF/AVG arm because the arteriovenous access is considered the patient's "lifeline" for dialysis 1.
- Arm veins suitable for vascular access must be preserved regardless of arm dominance, and should not be used for venipuncture or intravenous catheters 1.
- This cautionary approach to avoid procedures in the fistula arm should be extended to all invasive devices, including IO access 1.
Specific Risks of IO Placement in the Fistula Arm
Infection risk: Patients with advanced chronic kidney disease have higher rates of coagulopathy and bleeding due to uremic platelet dysfunction, which increases infection risk with any invasive procedure 1. IO devices carry inherent infection risks including osteomyelitis 1, 2, and introducing this risk to the fistula arm could lead to catastrophic access loss.
Compartment syndrome: IO placement complications include compartment syndrome 1, 3, which in the fistula arm could compromise both the IO site and the fistula's venous outflow, potentially causing fistula thrombosis.
Extravasation and tissue damage: IO complications include extravasation of medications and fluids into soft tissue 2, which could damage the superficialized veins used for fistula cannulation or cause local inflammation that interferes with dialysis access 4.
Practical Clinical Approach
Alternative IO Sites
- Use the contralateral arm (the arm without the fistula) for humeral IO placement 1.
- Use the tibia as the preferred alternative site, with insertion 2 cm distal to the tibial tuberosity and 1 cm medial to the tibial plateau 1.
- The sternum is another option in adult trauma patients using appropriate devices 2.
Patient Education and Protection
- Patients with chronic kidney disease (creatinine ≥3 mg/dL) should wear a Medic Alert bracelet to inform emergency personnel to avoid IV cannulation and other invasive procedures in the fistula arm 1.
- Hospital staff must be instructed to protect arms from venipuncture and intravenous catheters in all patients with progressive kidney disease 1.
Emergency Considerations
- IO access should be removed as soon as suitable IV access is achieved, ideally within 24 hours of placement 1, 2.
- In true emergencies where the fistula arm is the only accessible site, the clinical decision must weigh immediate life-threatening needs against long-term dialysis access, but this scenario should be extraordinarily rare given multiple alternative IO sites available 1, 2.
Critical Pitfall to Avoid
Never place an IO device in the arm with an arteriovenous fistula or graft. The risk of compromising the patient's dialysis access—which may have taken months to mature and represents their only viable option for life-sustaining hemodialysis—far outweighs any perceived convenience of using that arm for emergency vascular access 1. Always use alternative sites (contralateral arm, tibia, or sternum) for IO placement 1, 2.