How should a hemodialysis patient with a biceps hematoma caused by needle penetration during a session be evaluated and managed?

Management of Biceps Hematoma from Hemodialysis Needle Infiltration

Apply ice immediately for at least 10 minutes, hold direct manual pressure for 30 minutes, avoid further cannulation at that site for up to 3 months, and closely monitor for compartment syndrome with urgent surgical consultation if any signs develop. 1

Immediate Management

First-Line Interventions

• Apply ice to the infiltration site for a minimum of 10 minutes to reduce bleeding and swelling 1
• Hold firm manual pressure directly over the infiltration site for 30 minutes before reassessing 1
• Do not occlude the AV access outflow distal to the hematoma during pressure application, as this can increase intraluminal pressure to arterial levels and worsen bleeding 1
• Refrain from maximizing the blood pump speed if dialysis is continuing 1

Critical Assessment Required

Perform immediate comprehensive evaluation including:

• Measure the extent of swelling in the biceps region and document size 1
• Assess flow in the AV access both proximal and distal to the hematoma by palpation and auscultation 1
• Evaluate circulation to the entire extremity including distal pulses, capillary refill, sensation, and motor function 1
• Monitor for signs of compartment syndrome: severe pain out of proportion to exam, pain with passive stretch, paresthesias, pallor, pulselessness, or tense compartments 2

Dialysis Access Decision

If Dialysis Must Continue That Day

• Cannulate proximal to the infiltration injury if the hematoma is significantly large 1
• Do not reattempt cannulation at or near the injury site until after 30 minutes of manual pressure and ice application 1
• Consider placing a temporary catheter if proximal cannulation is not feasible 1

Access Rest Period

A significant hematoma requires placement of a CVC and deferral of further AV access cannulations until the hematoma is completely resolved, which may last up to 3 months. 1 This extended rest period is critical because:

• Premature recannulation of an infiltrated access carries high risk of inaccurate cannulation 1
• Further attempts can exacerbate existing swelling and lead to permanent access loss 1
• Single infiltration injuries reduce overall AVF maturation odds by 56% 1

Diagnostic Evaluation

Imaging for Large Hematomas

Bleeding requiring skin sutures or resulting in very large hematomas is highly suggestive of venous outflow stenosis and requires referral for diagnostic angiogram. 1 This is a critical pitfall to avoid missing.

Ultrasound Assessment

• Use bedside ultrasound by trained operators to assess flow direction and vessel patency if available 1
• Ultrasound can help determine the extent of hematoma and guide future cannulation decisions 1

Monitoring for Complications

Compartment Syndrome Surveillance

This is the most critical complication to monitor for, as it requires emergent fasciotomy. 2 The biceps location makes subfascial hematoma progression to compartment syndrome possible, particularly if:

• Heparinized dialysis continues after the injury 2
• The hematoma is not detected initially and progresses 2
• Patient is anticoagulated or has coagulopathy 3, 4

Signs requiring immediate surgical consultation:

• Severe pain disproportionate to physical findings 2
• Pain with passive muscle stretch 2
• Progressive swelling with tense compartments 2
• Neurological deficits (paresthesias, weakness) 2
• Diminished distal pulses 2

Coagulation Management

• Check baseline coagulation studies including PT, aPTT, platelet count, and fibrinogen if the hematoma is large 5
• Consider reversal of anticoagulation if patient is on warfarin or other anticoagulants and bleeding is significant 5
• Hold heparin during subsequent dialysis sessions until the hematoma resolves 2

Pain Management and Patient Support

• Provide analgesics on an individual basis depending on severity of pain and patient anxiety 1
• Offer comfort measures and education to the patient and family about expected recovery timeline 1
• Pain can persist after dialysis and may indicate nerve irritation requiring further evaluation 1

Prevention of Stenosis

Development of significant hematomas can result in stenosis at the site of injury, which is why avoiding these complications through proper cannulation technique is paramount. 1 If stenosis develops, it will require intervention to maintain access patency.

Common Pitfalls to Avoid

• Do not attempt recannulation before complete hematoma resolution (up to 3 months may be needed) 1
• Do not miss compartment syndrome - maintain high index of suspicion with serial examinations 2
• Do not overlook underlying venous stenosis - large hematomas warrant angiographic evaluation 1
• Do not continue heparinized dialysis through the injured access - this can cause hematoma progression 2