Peripheral IV Placement in the Arm with a Non-Functioning AV Fistula
No, a peripheral IV should not be placed in the wrist or forearm of an arm with a non-functioning AV fistula, as this extremity must be protected to preserve future vascular access options and prevent complications that could permanently compromise dialysis access.
Core Principle: Arm Protection Regardless of Fistula Function
The arm with a fistula or graft must be protected from any invasive procedures, including IV lines, blood draws, and blood pressure measurements, regardless of whether the fistula is currently functioning 1.
This protection applies because the arteriovenous access is considered the patient's "lifeline" for dialysis, and any damage to the arm's vasculature could preclude future access creation 1.
Even if the current fistula is not working, the arm's veins and arteries remain critical for potential revision, new access creation, or alternative access procedures 2.
Why Non-Functioning Fistulas Still Require Arm Protection
Arm veins suitable for vascular access must be preserved regardless of the current fistula status, as these veins may be needed for future access procedures 1.
Previous vascular access procedures (including failed fistulas) already limit available sites for future access creation 2.
Any additional venous damage from peripheral IV placement could permanently eliminate the possibility of creating a new functional access in that extremity 3.
The average life expectancy of hemodialysis patients has increased, meaning many patients will require secondary or tertiary access procedures over their lifetime 4.
Specific Risks of IV Placement in the Fistula Arm
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.
Peripheral IV placement can cause venous thrombosis, which would further compromise already limited vascular access options 1.
Previous invasive procedures (including IV lines) are documented risk factors for venous abnormality that makes construction of standard AVF difficult 3.
Female gender and history of previous surgery are independent risk factors for inadequate veins, making vein preservation even more critical 3.
Clinical Algorithm for IV Access
When a patient has a non-functioning AV fistula:
Use the contralateral arm for all peripheral IV access 1.
If the contralateral arm is unavailable, use the dorsum of the hand on the non-fistula arm rather than forearm veins 5.
If neither arm is suitable, consider:
- Lower extremity peripheral IV access
- External jugular vein access
- Ultrasound-guided peripheral IV in non-fistula extremities
- Central venous access via internal jugular vein (never subclavian) 5
Never use the fistula arm unless it is a true life-threatening emergency with absolutely no other options available 1.
Vein Preservation Strategy
All arm veins in patients with advanced kidney disease should be preserved for potential future vascular access, regardless of current fistula status 5.
Venipuncture and IV lines should preferentially use the dorsum of the hand rather than arm veins in the non-fistula extremity 5.
Healthcare professionals must be educated about the importance of vein preservation in these patients 5.
Patients should wear a Medic Alert bracelet to inform emergency personnel to avoid IV cannulation and other invasive procedures in the fistula arm 1.
Common Pitfalls to Avoid
Do not assume that a non-functioning fistula means the arm is "available" for IV access - the entire extremity remains off-limits 1.
Do not place IV lines in forearm veins of either arm in dialysis patients when hand veins or alternative sites are available 5.
Avoid the misconception that "just one IV" won't cause harm - even single venipunctures can damage vessels needed for future access 3.
Never use subclavian vein catheterization in these patients, as it causes central venous stenosis that can permanently preclude use of the entire ipsilateral arm 5.