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DialysisProcedures

DialysisProcedures
Itissimple.Thereareonly3procedures:
Initiation Monitoring Discontinuation

Well,maybenotsosimple

InitiationofDialysis
PreDialysisSafetyChecks InitiationProcedures ImmediatePostInitiation Procedures

Predialysis SafetyChecks
Watersystem
Temperature Resistivity Residualdisinfectant

PrescribedDialyzer&Concentrate DialysisMachineSafety
Alarmsactive Dialysate conductivity&/orpH

IntegrityofExtracorporealCircuit IfDialyzerReused
Checkpatientsnameonlabel Disinfectantresidualtest

Predialysis PatientEvaluation
PhysicalParameters
Weight BP (stand & sit) Temp Pulse & Resp Complaints

EvaluateAccessStatus
Signs of infection redness, tenderness,
unusual warmth, purulent drainage

Patency
Graft & AVF: bruit, thrill Catheter: easy aspiration (post disinfection)

Direction of flow (identify A & V)

FollowUniversalPrecautions
Wash hands Glove Gown Eye protection Mask

InitiationofDialysis
Graft/Fistula
Select sites Disinfect Anesthetize Insert needles

Catheters
Disinfect catheter limbs Aspirate heparin from limbs Evaluate patency

DrawBloodWork
Prior to administering heparin From arterial port Administer heparin post draw

InitiateBloodFlowtoDialyzer
Connect lines Start at low BFR

PostInitiation
Calculate/ApplyTMP
Fluid gain/ # Hours = UF vol (ml/hr) UF Volume/ UF Coefficient = TMP TMP = V resistance + Neg pressure

Setmachineparameters
BFR DFR UFR Alarm limits Dialysate temp Heparin Infusion rate

Patientcomfortmeasures

Charting
Overridingobjectives
Complete Legible

Treatmentdocumentation
Prescribedparameters Pre&Postpatientassessment Vitalsignsduringtreatment Medicationsgiven Treatmentparameters
BFR,DFR,A&Vpressures,TMP/UFR

Patient/machinecomplications Yoursignature

Monitoring DuringTreatment
Detectionof Complications
BloodRelated Dialysate Related PatientRelated

ExtracorporealCircuit Pressures Anticoagulation TreatmentFactors


ImpactonClearance

Charting

BloodSideComplications
AirinBloodCircuit
Minor:usualcauseiscarelesssetup,drip chamberlevelwilldrop,alarmwillsound

AirEmbolism
Major:airdetectoralarmfailure

BloodLoss AccessRecirculation Clotting PoorBFR NeedleInfiltration

Dialysate SideComplications
Dialysate Temperature
Hypothermia Hyperthermia

Hemolysis
Dialysate temperature, kinkedbloodlines, formaldehydeindialysate lines,inadequatewater treatment(chloramines, copper,zinc,nitrates)

Crenation
Hypertonicdialysate

PatientRelatedComplications
Hypotension Hypertension MuscleCramps Headache Nausea&Vomiting Headache Fever&/orChills Fistula/GraftInfection,Thrombosis FistulaAneurysm,Psuedoaneurysm CentralVenousCatheterInfection CatheterThrombosis CardiacDysrhythymia Pericarditis,pericardialeffusion, cardiactamponade DialysisDisequilibriumSyndrome FirstUseSyndrome Seizures Angina Anaphylaxis Pruritis StealSyndrome CardiacArrest DialysisEncephalopathy(Al++)

Extracorporeal CircuitPressures
BloodSide
ElevatedPrePumpArterialPressure
RBCdamageifgreaterthan250mmHg Increaseindicatesobstructionofbloodflowintopump

ElevatedPostPumpArterialPressure
Increaseindicatesobstructionofbloodflowintodialyzer

ElevatedVenousPressure
Increaseindicatesobstructionofbloodflowintopatient

Dialysate Side
FailureofNegativePressurepump

WatchBoth Transmembrane Pressureiskey

Anticoagulation
Threemethods
Saline flush
Flush blood circuit with saline q 30 min No drugs No bleeding risk during or post dialysis

Trisodium citrate
Difficult: requires 2 infusion pumps, 0 Ca++ dialysate No bleeding risk during or post dialysis BUT maintaining patients calcium balance is difficult & risky Citrate is metabolized into bicarbonate

Heparin

TwoHeparinMethods
Systemic
Method:bolus+constantinfusion untillasthour Objective:maintainACT1.52.0 baseline

TightSystemic
Method:samebutlowerdoses Objective:maintainACT1.21.4 baseline

TreatmentFactors: ImpactonClearance1
BloodFlowRate
BFR smallmolecule(ex.urea)clearance BFRhasmuchlesseffectonlargemolecules

Ultrafiltration Rate
UFRwillresultin clearance,viasolutedrag Mainlyinvolveslargermolecules Minimaleffectontotalclearance

Dialysate flowrate
DFRwill clearance Minimaleffectontotalclearance
IfBFR>350,hifluxdialyzer,500DFR 800DFR=Curea 510%

TreatmentFactors: ImpactonClearance2
Anticoagulation
Clottingreducesavailablemembranesurfacearea,thusclearance

TreatmentTime
Longertime= clearance Shortertime= clearance
5min perTx X156Tx/yr=780minor>3dialysis/yr

AccessRecirculation
Causes:needlestooclose,accessstenosis,cardiopulmonary recirculation Result:freshlydialyzedbloodmixeswithuremicbloodbeing drawnintothearterialbloodline

Discontinuation
TerminationofTreatment NeedleRemoval/CatheterCare PostDialysisPatientAssessment Documentation PostDialysisMachineCare

TerminationofTreatment
DiscontinueHeparininfusion
Perunitprotocol(usually3060minpreD/C)

Chartpatient&machineparameters D/CTMP Drawpostdialysisbloodsamples


ReduceBFRto100ml/min,wait 15seconds Alternative:drawseveralminutespostdialysis

Returnbloodtopatient CheckpatientsBPbeforedisconnection
Incasefurtherfluidinfusionisrequired

NeedleRemoval
Removeoneneedleatatime Withdrawatsameangleasinsertion Applypressureovervessel(notskin)insertionsite Amountofpressurematters
Toolittle:prolongedbleeding,hematomaformation Toomuch:clottedaccess

Clean&dresssiteafterbleedingstops
Note:Iffistulaclampsused,shouldfollowstrictprotocol becauseapplicationofproperpressureisdifficult.

CatheterCare
Priortoremovingdialysislines,disinfectcatheter portswith:
Providone iodineor Chlorhexadine gluconate

Flusheachcatheterlumenwithnormalsaline Instillheparinintoeachlumen
5,00010,000unitsperlumenismostcommondosagerange NOTE:volumeofheparinshouldjustbarelyexceedlumenvolume

Placefreshsteriledressingovercathetersite Labelcathetersite
DONOTFLUSH #unitsheparinperlumen Dateandinitialsofstaffmember

PostDialysis PatientAssessment
Vitalsigns
BPsitting&standing TPR

Physicalassessment
Heart&lungsounds Edema Weight(fluidloss)

Vascularaccess Patientsymptoms
Patientcomments,complaints

Overallconditionobservations
Generalcondition,behavior,mentalstatus

Documentation
Dialysisdata
Timestopped Volumeofrinseback saline Bloodloss,ifany(includeclotsindialyzer,dripchambers)

Patientcondition
Vitalsigns,physicalassessment Overallcondition,includingvascularaccess

Specialinstructionstopatient,ifany Time&methodofdeparture

PostDialysis MachineCare
Disconnectandrinseconcentratelines Removedialyzer&bloodlines
Disposeinhazardouswastecontainer Iftobereused
Ensurefilledwithsalineorheparinized saline,perunitprotocol EnsureproperlylabeledwithpatientIDdata Delivertoreuseareawithin1015minpostdialysis

Removeotherdisposables
Disposeinhazardousornonhazardouswastecontainer, asappropriate

Remove&disinfectnondisposables(ex.clamps) Clean&disinfectoutsideofmachine

DialysisProcedures

Summary
Initiation Monitoring Discontinuation
Itisnotsimple!

YOUarethekey.

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