What are the usual patient instructions post Arteriovenous (AV) fistula creation for Hemodialysis (HD)?

Post-AV Fistula Patient Instructions for Hemodialysis

Patients should be instructed to perform daily hand-grip exercises (squeezing a rubber ball) to promote fistula maturation, keep the access arm clean by washing with soap and water before each dialysis session, avoid any trauma or constriction to the access arm, and monitor for signs of complications including infection, swelling, or changes in the thrill. 1

Immediate Post-Operative Care

Arm Protection and Activity Restrictions

• Never allow blood pressure measurements, blood draws, or IV insertions in the access arm 1
• Avoid wearing tight clothing, watches, or jewelry on the access arm that could compress the fistula 1
• Do not sleep on the access arm or carry heavy bags/purses on that side 1
• Avoid lifting heavy objects (>10-15 lbs) with the access arm during the maturation period 1

Daily Fistula Assessment

• Check the fistula daily by feeling for a "thrill" (vibration/buzzing sensation) over the access site 1
• Listen for a "bruit" (whooshing sound) by placing your ear near the fistula 1
• If the thrill or bruit disappears or changes significantly, contact your dialysis team immediately as this may indicate thrombosis 1

Fistula Maturation Exercises

Hand-Grip Strengthening Protocol

• Perform isometric hand-grip exercises by squeezing a rubber ball or stress ball for 10-15 minutes, 3-4 times daily 1
• These exercises can be done with or without a lightly applied tourniquet 1
• Continue exercises for 4-6 weeks post-creation to enhance vein maturation and increase blood flow 1
• The resulting muscle mass increase enhances vein prominence and decreases superficial fat 1

Hygiene and Infection Prevention

Pre-Dialysis Access Care

• Wash the access arm with soap and water before each dialysis session 1
• Examine the access site for signs of infection including redness, warmth, tenderness, swelling, or drainage 1
• The dialysis staff will disinfect the site with alcohol-based chlorhexidine (>0.5%), 10% povidone iodine, or 70% alcohol before cannulation 1

Signs of Infection Requiring Immediate Attention

• Redness, warmth, or tenderness at the access site 1, 2
• Purulent drainage from the fistula 1, 2
• Fever or chills 1, 2
• If infection is suspected, contact your dialysis team immediately—infections require 6 weeks of antibiotic therapy and the access must not be used until cleared 2

Post-Dialysis Care

Needle Removal and Hemostasis

• After needle removal, apply firm pressure to the puncture sites for at least 10-15 minutes 1
• Do not bend the arm or lift heavy objects for several hours after dialysis to prevent bleeding or hematoma formation 1
• If bleeding continues beyond 20-30 minutes, apply ice and contact your dialysis team 1
• Some oozing is normal, but active bleeding or large hematomas require evaluation 1

Monitoring for Infiltration

• Watch for signs of infiltration including sharp pain, swelling, or discoloration at needle sites 1
• If infiltration occurs, the fistula should be rested for at least one dialysis treatment 1, 2
• Apply ice immediately to decrease pain and size of infiltration 1, 2
• Elevate the arm as much as possible to reduce swelling 2

Warning Signs Requiring Immediate Medical Attention

Critical Complications

• Loss of thrill or bruit—may indicate thrombosis requiring urgent intervention within 24-48 hours 1
• Severe pain, coldness, numbness, or weakness in the hand (steal syndrome) 1, 3
• Fingertip discoloration, pain, or tissue necrosis—delay can lead to catastrophic limb loss 1, 4
• Excessive swelling that persists beyond 2 weeks—requires imaging evaluation 2
• Signs of infection as described above 1, 2

Steal Syndrome Recognition

• Coldness in the hand, especially during dialysis 1, 3
• Pain in the hand or fingers, particularly with hand use 1, 3
• Numbness or tingling in fingers 1, 3
• Patients with diabetes, hypertension, or peripheral arterial disease are at highest risk and should be especially vigilant 1, 4

Maturation Timeline and Expectations

When Can the Fistula Be Used?

• Most fistulas require 6-12 weeks to mature before first use 1
• A fistula that only works with a tourniquet in place is still underdeveloped and needs more time or reevaluation 1
• Initial cannulation typically uses smaller needles (17G) with gradual progression to larger sizes 1
• Blood flow rates will be limited initially and increase as the fistula matures 1

Common Pitfalls to Avoid

• Never apply pressure to needle sites before the needle is completely removed—this can cause infiltration 1
• Do not allow anyone unfamiliar with fistula care to access your arm 1
• Avoid dehydration, which can increase thrombosis risk 1
• Do not ignore subtle changes in thrill or bruit—early detection prevents access loss 1, 2
• If swelling persists beyond 2 weeks despite rest and elevation, imaging is required to evaluate for underlying stenosis or other complications 2