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The use of an ESRD patient’s dialysis access in the prehospital setting should be reserved for the critical, rapidly decompensating patient when intravenous and intraosseous access cannot be obtained during resuscitation efforts. While the risks of complications (e.g., thrombosis, infection) may ultimately result in the loss of the patient’s graft, fistula, or catheter, these issues can be dealt with later, pending the patient’s survival.

Both AV fistulas and AV grafts can be accessed in a fashion similar to starting a peripheral intravenous line. Gloves, eye protection, and a mask should be used along with aseptic technique to the extent possible. A tourniquet should be loosely applied to the axilla proximal to the access site, tight enough to cause the vessel to engorge, and be removed immediately after cannulation of the fistula or graft. A large‐bore needle (14, 16, or 18 gauge) with or without an angiocatheter should be inserted into the fistula at 20‐35 degrees (45 degrees for graft access) until a flash of blood is seen. The needle should be advanced 3‐4 mm before flattening the angle of insertion flat against the skin and threading the needle alone or with a catheter until the hub rests against the insertion site. The line needs to be secured in place. Due to the high‐velocity blood flow in the graft and fistula, saline lock tubing and a pressure bag for fluids will be needed, especially for access using an angiocatheter. When appropriate, the EMS clinician should assess for a thrill at the access site and relay this information to the receiving facility [40].

Dialysis catheters, whether tunneled or nontunneled, essentially function as central lines. The dialysis catheter usually has two lumens attached to two ports, red and blue. The red port is considered arterial and the blue port venous, tasked with bringing filtered blood from the dialysis machine back to the heart. A third port, white in color, may be present specifically for blood draws and medication administration. In the absence of the white port, the blue “venous” port should be used for emergency administration of drugs and fluids. Personal protective equipment should be donned to keep the procedure as sterile as possible. The port cap should be cleaned with chlorhexidine or alcohol, and the lumen should be clamped while the cap is removed. After cleaning the catheter hub, a syringe should be attached, and the lumen unclamped. As information regarding the locking fluid present in the catheter will likely not be immediately available to the EMS clinician, fluid and blood should be withdrawn with a 10 cc syringe and wasted before administration of medications. This is to prevent inadvertent systemic administration of the locking solution. The lumen should be flushed and clamped after drug administration. Replacement of locking fluid and caps can occur in the hospital setting.

During emergency transport from a dialysis center, the staff at the facility may leave the ESRD patient’s vascular device accessed. EMS personnel should be aware of this as a potential site for emergency drug administration and should protect the access point from trauma.