If an appropriate-sized piece of Gelfoam was utilized, the product should be absorbed completely with little tissue reaction. Once adequate hemostasis is achieved, a compressive bandage may be gently but firmly applied. Again, care should be taken not to occlude the AV graft with compression from this bandage. If one piece of Gelfoam did not achieve hemostasis, another piece may be added on top and the process repeated.

Topical thrombin. Long used in surgical hemostasis, topical thrombin has shown utility in the acute management of vascular access hemorrhage. At its inception, thrombin was bovine derived, but its use was complicated by antibody development that could cross-react with human anticoagulation factors, resulting in anaphylaxis and death. In an effort to minimize these risks, thrombin that is isolated from human plasma donors was developed. Use of human thrombin is limited by the possibility of transmitting blood-borne pathogens. Therefore, FDA-approved recombinant thrombin has recently been developed, with the specific advantages of being minimally antigenic and having less risk of viral disease transmission.¹⁹

Thrombin can be used alone or in combination with an absorbable hemostatic carrier such as Gelfoam, microfibrillar collagen, or oxidized regenerated cellulose. These agents are all structurally porous in nature, providing a framework for platelet and coagulation factor activation.¹⁹

Brand names for topical thrombin include Evithrom, Recothrom, Thombi-Gel, Thrombi-Pad, and Thrombin-JMI.²⁰ Dosing for any of these agents is dependent on the area to be treated and are applied to the bleeding or oozing surfaces directly.

The use of thrombin and absorbable hemostatic agents is well established in several surgical settings. This effectiveness in accelerating hemostasis in moderate to severe bleeding can be applied to the management of vascular access hemorrhage in the emergency department. However, the expense of these agents may prohibit their routine use in minor bleeding.

Desmopressin. Also known as 1-deamino-8-d-arginine vasopressin, DDAVP is a derivative of antidiuretic hormone. Although the literature does not describe DDAVP’s use for the specific management of bleeding AV grafts, there is evidence to support its use in this patient population when they present with other sites of bleeding.

Initially indicated for the treatment of hemophilia A and von Willebrand disease (vWD), today intravenous DDAVP may be used by the emergency physician to manage hemorrhage from either AV grafts or fistulae by negating the platelet dysfunction commonly seen in ESRD patients.

DDAVP’s mechanism of action is currently not well understood, though it has been shown to decrease both activated partial thromboplastin and bleeding times in uremic patients despite the actual platelet count being unaffected.¹⁸ It has also been shown to help prevent bleeding before invasive procedures in dialysis patients.²¹