Steal syndrome

Hi Dr. Agar,
Do nocturnal patients dialyzing in bed, as opposed to a chair, sometimes have more problems with steal syndrome? If so, is there a way they should position their access arm so as to avoid numbness to the hand? If one is asleep and does not notice that ones hand is going numb, can that in any way damage the access or cause other problems?

Dear Jane

The symptoms of a ‘Steal Syndrome’ in a vascular access are not primarily or usually associated with the stated symptom in your question of ‘going numb during dialysis’ (or of ‘pins and needles’ in the affected hand) – symptoms almost always as a result of positional issues and pressure on a nerve (usually the ulnar nerve at the elbow) – but, rather, are all to do with pain, pallor and coldness in the affected hand.

Your question “Do nocturnal patients dialyzing in bed, as opposed to a chair, sometimes have more problems with steal syndrome” … is therefore answered with a ‘No’ – as there is really no reason why this should happen.

But your next question … “is there a way they (I assume here you mean nocturnal patients) should position the access arm so as to avoid numbness to the hand?” … here, I would answer ‘Yes” … and, “If one is asleep and does not notice that ones hand is going numb, can that in any way damage the access or cause other problems?” … another broad ‘No’.

I think you appear to be confusing two largely separate issues here.

  1. The ‘Vascular Steal Syndrome’ is a real (and sometimes nearly impossible-to-fix) problem that afflicts some dialysis patients. This is more acutely so of some diabetic patients and in others who have accelerated blood vessel disease affecting their arterial circulation. … for example: patients with systemic sclerosis or severe hypertensive states are among the others especially at risk of this problem. In these situations, arterial blood flow to the limbs may already be impaired even before a fistula is fashioned but which, after fistula formation, can be exacerbated (ie: made worse).

To make a fistula, the artery (commonly the radial at the wrist or the brachial at the elbow) is linked, surgically, to a nearby vein … and there are many and varied ways to surgically do this which I will not explore here. Suffice to say that this ‘diverts’ some of the blood flow which otherwise would have flowed on to the hand back, into the vein and thus back to the heart (as veins carry blood back to the heart). This has the effect of ‘distending’ the vein with higher pressure and flow blood, making it easier to ‘ping’ with a needle while also improving the flow rate in the vein so that adequate flows are then available for dialysis. But … as a result, the ongoing blood flow to the hand can be compromised. Usually (and luckily) this doesn’t happen as there are fortuitously two ways in which the hand receives its blood circulation …. (1) down the radial artery - on the thumb side of the inner surface of the wrist … and (2) down the ulnar artery - on the little finger side of the inner surface of the wrist.

If both circulations are intact … it’s usually tickety-boo as, even if one of these arterial supplies to the hand is impaired or reduced, the other is not disturbed and over-all blood flow is sustained.

But, if there is trouble with a damaged arterial tree (eg: previous surgery, prior vascular disease - as above) or just plain bad luck … sometimes the ulnar artery (for example) can be spindly and thin and this is sometimes not all that easily picked up prior to fistula creation … and, no, this really is no-one’s fault – there really is a lot of ‘just plain bad luck’ in all of medicine and surgery that really is no-ones fault.

The result, however, is … a diminished (and sometimes critically so) circulation to the hand.

The blood is ‘stolen’ by the fistula. The hand is ‘robbed’ of adequate blood flow. The hand – and this may be especially so during dialysis when the machine is ‘robbing’ even further but may be a constant problem even between dialysis treatments – becomes pale, cool, and ‘ischaemic’ (a medical term for lacking blood flow).

The main symptom is pain, sometimes unremitting pain … and the ‘fix’ is usually surgical. There are all sorts of specialized surgical techniques (like the DRIL procedure) to try to fix this problem … but these ARE specialized and best left for individual discussion between the surgeon and the patients, should these be – and they are rarely needed, given the number of fistulae that give no trouble at all.

So … a steal = pain … not the numbness I am reading (I trust correctly) from your question.

  1. Numbness in a limb distal (beyond) the fistula during dialysis is almost always a positional issue.

A good fistula, well needled, well taped, well secured … and especially in the nocturnal patients where buttonholing may be more commonly used … with blunted needles in place – is safe.

Move the arm!

Use it!

Roll over (as I do, in my sleep) … and so should a patient on dialysis during sleep!

OK … the line might kink. But, if it does, the alarm will tell you.

We do not encourage rigid ‘positioning’ of the arm. Limb rigidity is unnatural. Limb rigidity impairs natural sleep. Limb rigidity leads to mucsular tiring - then aching. Limb rigidity also can put undue pressure on vulnerable nerves - especially the ulnar nerve at the elbow and sometims the radial nerve too.

Solution? … Move the arm. Use it. It’s an arm. An arm is designed to be a mobile, useful thing. Dialysis (good dialysis) should be also designed to offer and sustain our physiology to as close to a normal state as is possible.

OK – I sense muttering – that is an impossibility on dialysis … mutter mutter …

Maybe so, in the full sense of the word ‘normal’ – I understand that – but let us ensure we embrace normality where we can. And a well needled, well taped, well secured, blunted needled fistula should be a mobile, usable fistula. Not to wrestle or saw wood with, true, but to move and stretch and roll with, yes!.

The symptoms you describe are like those we have all experienced … the pins and needles of keeping pressure on an elbow too long … or a bang on the ‘funny bone’ – the ulnar nerve as it curves round the bony point under the elbow and is subject, now and then, to local ‘trauma’!

The symptoms you have ascribed (I think with confusion) to a ‘steal syndrome’ are much more likely those of a fearful or over-anxious patient who is too scared to move the arm normally, to alter its position, to flex its muscles, to ‘stretch’ … and we all know how yummy a good stretch is when we wake in the morning and need to get our immobilized body up and running again.

  1. Finally – is the numbness harmful … no, not really. Left for too long, it can cause pressure damage to the nerves but this is unlikely in a dialysis situation. This is more likely in situations like orthopaedics when a plaster cast is applied incorrectly but in an nocturnal dialysis patient … I think not. At least, this hasn’t been something we have experienced. On the other hand, our patients roll, and move, and use (while awake, at least) and sustain a mobile fistula arm. Doing that will solve pretty much all the numbness issues you raise.

John Agar