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HEPARINIZATION During dialysis the patient’s blood comes into contact with man-made materials. This contact may allow the blood to clot. The goal of hemodialysis is to move the blood out of the body, clean it, and return it as quickly as possible. There is no time for clotting. If the blood clots, the hemodialysis process is much more difficult and may need to be halted. Heparin is a ‘blood thinner,’ or anticoagulant which works inside the body to prevent blood from clotting. The nurse practitioner and/or physician will order the amount of heparin each patient is to be given during a hemodialysis treatment. Typically patients are given a large dose of heparin, a loading dose, at the beginning of a treatment. Then small amounts, continuous infusion, are given during the treatment. The initial large dose helps to ‘jump-start’ the anticoagulation process. This way the hemodialysis procedure will more than likely function more smoothly. Care must be taken when administering heparin not to give the patient too much. Accuracy is imperative here. Heparin is bottled in three ways or three concentrations, 1:1,000, 1:5,000, or 1:10,000. Before using heparin on a patient be certain you have the correct concentration. (See drawing medications) After verifying the proper concentration, check the doctor’s order to verify the correct dosage. The machine allows for heparin to be slowly injected during the hemodialysis treatment. The doctor often orders for the injection to stop approximately one hour before the end of the dialysis treatment. Why would they do that? Heparin takes four to six hours to stop working. Therefore, if you give the patient heparin up until the last minute, when you remove the two large needles in his arm, it will take a VERY long time to clot. Stopping the heparin 60 minutes prior to the termination of dialysis will allow most patients’ blood to clot in ~15 minutes. -1- COMPLICATIONS When giving any medication is it vital to know the possible complications. Too much heparin: Prolonged bleeding after dialysis Nosebleeds Easy bruising Stomach bleeding Hematuria (blood in urine) Too little heparin: Clotting of the dialyzer completely or a little Poor rinseback MONITORING AND TREATING A PATIENT DURING HEMODIALYSIS Patients must be started on dialysis, monitored during dialysis, and then discontinued from dialysis. Seems obvious, right? Let’s go through the steps. Before we touch, a patient we must first greet them. Patient care is our priority and this includes the patient’s physical as well as mental well being. Identify yourself if the patient doesn’t know who you are. Be friendly and try to establish a positive relationship with your patients. COMMUNICATING All people communicate by means of verbal and non-verbal communication. Verbal is what is said and non-verbal is obviously what is not said but rather observed. I’m sure you’ve seen someone who ‘appears’ to be anxious, or frightened. Or you’ve probably heard the term, “actions speak louder than words,” this is what I’m referring to. What we do is a means of communication, subject to interpretation by others. Did you ever stop to think that even failure to act is a way of communicating? (5) Non-verbal communication includes facial expressions, eye contact, tone of voice, body posture and motions, and positioning within groups. When watching a patient or greeting a patient, ask the patient how they are feeling, then listen. I mean really listen. Listen carefully to be sure you truly hear what the say and watch their non-verbal communication to see if the verbal matches the non-verbal. Most dialysis patients return every other day. If you work with the same group week after week, you will surely get to know these people. You’ll be able to ‘read them’ and know if they are not feeling their best. -2- If a patient is not feeling well, they may hold their head down, walk more slowly, talk in a softer voice, and not have a happy look on their face. Regardless of what the patient is communicating, be ready to provide emotional support and/or accommodate emotional needs as necessary. If the patient does not hear well, it will be important to speak more slowly, louder and clear. If the patient speaks a language other than any language you know, special accommodations must be made. Communicating with your patient is imperative. Patients that are older may be addressed differently than patients that are younger. Finally, before attempting any procedure on a patient, you must first explain what you are doing. If the patient requires further explanation, beyond what you can do, you must contact your nurse to assist. It is not proper or legal to perform any procedure on a patient without their permission. If the patient doesn’t understand what is going to take place, they will more than likely not give permission. STARTING OR INITIATING DIALYSIS The dialysis machine must be setup and ready for the patient. The machines are disinfected during the night. This cleaner must be rinsed away before using on a patient. Once this is rinsed, the machine must be tested to verify all poisons have been removed. Now you can set up the machine. Set up the machine according to the hands-on instruction given. Keep the cartridge well seated before closing the pump. Prime the pre-dialyzer tubing by gravity before connecting to the dialyzer to prevent air locks. Use 1,000 cc of saline to prime the dialyzer. While priming the dialyzer, tap and roll the kidney to work as much air as possible out. Most dialysis machines use acid and bicarb to create the concentration differences discussed in the beginning. These solutions or powders will need to be connect and set-up during the initiation/set-up phase. Connect the tubing to recirculate. A reuse kidney will need to recirculate for eight plus minutes before testing to verify the Renalin has been removed. If using a dry-pack, recirculate for two minutes as another way of verifying the kidney will give the patient maximum performance. When the Renalin test is complete perform machine and venous high-pressure tests. -3- Connecting to the patient There are several things to consider before connecting to the patient. The patient’s access must be used. ACCESS Dialysis cannot occur without a proper access. Large amounts of blood are going in and out of the patient at a very high speed. If the patient’s access is not working well, this process is greatly impeded. This hemodialysis access is similar to an IV that may be seen with many patients in a hospital. However, it is much much larger. Vascular accesses are the lifeline of a hemodialysis patient. There are many types, but four are seem most often: Fistula, Graft, Permacath, and ‘Shilley.’ These four are listed in order of best to worse. FISTULA A fistula requires a surgical procedure where the patient’s own vein and an artery are sewn together. Typically the veins and arteries in the arm are used. After the surgery, these sutures must heal and mature. Once a ‘native’ fistula is matured, it can be punctured repeatedly and remain in good condition. Native fistulas have fewer complications than any other type of access. The surgeon can connect these two vessels either side by side, end to end, or side to end. However, some patients are not candidates for this type of surgery. If the patient has had previous surgeries (6) to the vessels in the arms, damage to the blood vessels from IV drug abuse and/or repeated bloodwork, atherosclerosis in the vessels, or few or poor quality veins to choose from, graft will more than likely be placed. GRAFT A graft sews a patient’s vein and artery together using a Gore-Tex tubing that resembles a natural vein. But this is NOT a vein and, therefore, cannot take the wear and tear a natural vein can. As a result, patients have complications more frequently. A Gore-Tex graft cannot be punctured in the same area repeatedly as well. The materials will breakdown and soon resemble a tattered piece of cloth if allowed. -4- PERMACATH Permacath’s are large IV type catheters that are place in the patient’s neck or shoulder. The large veins used lead a path that goes directly to the patient’s heart. Therefore, sterility must be closely maintained. These central catheters, as they are sometimes called, have two ports available, just as placing two needles into a fistula or graft. What separates these catheters from a more temporary catheter is a cuff near the end that exits the body. This cuff is similar to a piece of Velcro. The Velcro is attached to the outside of the tubing. This cuff ‘grows into’ the fatty part just under the skin. When this occurs, the catheter is more stable. Typically a patient can use this catheter several months without any problems. SHILLEY Shilley catheters or temporary access catheters are similar to permacaths in that they are placed in the same large vein. The major difference is there is no cuff. These catheters are sewn onto the skin and the sutures hold it in place. Once the sutures are removed, it can easily be taken out. These catheters are used for only a few weeks. Once you know which type of access a patient has, you can proceed. Step one would be to wash your hands and don gloves, as standard precautions. Next inspect the site. Check the skin for any signs of infection, redness, heat, open sores, etc. Note where the site has been previously punctured. Avoid sticking the patient in the same place. An aneurysm can form if needles are inserted too often in the same area. The vessel wall will become weak and balloon out. This weak area of the vessel may become so thin that it leaks into the skin. Avoid pseudoaneurysms as well. These are bulges in an access that appear similar to an aneurysm with the ballooning out appearance, but these are not caused from weak vessel walls, but rather a collection of blood and blood clots ‘stuck’ in one area. Pseudoaneurysms often occur when improper techniques are used after needles are removed. NEVER insert a needle into an aneurysm or a pseudoaneurysm. If done, the vessel could rupture and/or become infected. -5- MONITORING THE PATIENT DURING DIALYSIS – INTRADIALYTIC During the patient’s dialysis treatment, you will monitor the patient’s status very closely. Every half-hour or more often ,you will check with the patient’s blood pressure, pulse, arterial pressure and level of consciousness. If there are no changes, you will simply continue to monitor. However, this is very unlikely. Patients may need help in repositioning themselves in the chair or bed or stretcher for maximum comfort. Often patients are given ice chips to eat during a treatment. These will need to be given to the patient. These are the easiest concerns you will have during a treatment. Let’s discuss some of the more involved issues. Patients are very limited in their movement for the 3-4 or more hours when they are receiving a dialysis treatment. The goal of dialysis is to remove fluid. By doing so, the patient’s blood pressure will naturally drop. Your job is to watch this blood pressure and if the values are significantly less than the original, an intervention will be needed. Typically the first step a dialysis staff member will do is to place the patient in a flat or Trendelenberg position. POST DIALYSIS After a dialysis treatment, the patient must be observed. The patient more than likely just had a large amount of fluid removed in a short period of time. When this occurs patient’s often feel tired or worn out and drained. As this fluid is being removed, a patient’s blood pressure will naturally fall. Therefore, when a patient stands up after a hemodialysis treatment he/she could feel dizzy or lightheaded. Listed below are the typical complications during hemodialysis: -6- -7- Complications Problem Causes Signs/Symptoms Air in Blood Lines ·In adequate blood flow rate, causing negative pressure, prepump (line collapses) Microfoam/Micro-bubbles Normal saline, if too cold when exposed to the warm dialysate, forms a type of condensation that causes tiny air bubbles to adhere to the dialyzer membrane and sides of the blood tubing. · A latex injection port does not self-seal (needle gauge greater than 20) · Underfilling of drip chambers (causes turbulence) · Underfilling of saline administration sets drip chamber · Improper deaeration (air removal) of dialyzing fluid · Residual air left in blood pathway after priming · Introduction of air during dialysis (especially together with absence of an arterial drip chamber) Not priming the heparin injection line prior to opening Inadequate connections pre-pump; i.e., fistula needle, saline, monitor line connections. “Foaming” in blood · Arterial blood line separation due to untapped, improper luer lock connection, or loose connections · Blood noted on floor, chair, and/or clothing · Hypotension · Air entering the extracorporeal circuit · Venous and/or arterial pressure may alarm (arterial and/or venous pressure should decrease) -8- Problem Causes Signs/Symptoms Blood Loss (accidental) · Venous blood line separation due to untapped, improper luer lock connection, or loose connections · Blood noted on floor, chair, and/or clothing · Hypotension · Venous pressure alarms (should be low venous pressure alarm) · Dialyzer leak · Dialyzer rupture · · · · · · · · · Arterial needle dislodgment · Arterial needle slips out · Venous needle dislodgment · Venous needle slips out Blood detector alarms Blood detector alarms Foamy pink to red-tinged dialysate Blood on floor, chair, and/or clothing Hypotension Venous and/or arterial pressure alarms (low limit alarm) Blood on floor, chair, and/or clothing Hypotension · Venous pressure monitor should alarm (low limit alarm) · Clotted blood in venous blood line · Venous pressure rises · Unable to return blood via venous line · Clots noticed in venous drip chamber · Clotted blood in arterial blood line · Arterial blood line with air in it (line “jumping”) · Possible decrease in venous pressure · Increase in arterial pressure · Unable to pump blood into dialyzer -9- Problem Hemolysis (Rupture of red cells) Due to hypotonic dialysate – diluted with too much water Causes Signs/Symptoms Improperly diluted dialysis bath composition due to failure of mixing system or human error: · Failure to connect concentrate · Huge rapid influx of water into circulation with the dilution of plasma – water moves across the cell membrane and dilutes intracellular constituents: - Decreased sodium, calcium, magnesium, and chloride · · · · · - · · · · · · · · · · Obstruction of dialysate concentrate source Malfunction of concentrate pump Faulty concentrate Failure of conductivity monitor significant calibration error fouling of probe complete failure failure to set correct limits in manual system failure to test dialysate in batch system Bypass mechanism failure mechanical failure - retrograde leak across bypass valve Due to overheated dialysate (temperature in excess of 470C) · “Cranberry juice” or “cherry pop” (clear) blood in venous line · · · · · · · · Failure of thermostat; heater turned on inappropriately Thermostat not set properly Failure of dialysate high temperature sensor High temperature sensor not set properly Calibration error in dialysate temperature range Major malfunction in heater cycle Dialysate temperature monitor failure Failure of machine to go into bypass - mechanical failure - retrograde leak across the valve - 10 - Decreased protein Pain in vein receiving hypotonic solution Warmth in throat Erratic blood pressure Chest pain or tightness Dyspnea Anxiety Restlessness Throbbing headache Nausea, vomiting, abdominal cramping, diarrhea Seizures · Arrhythmias – initially decreased pulse leading to rapid and thready pulse · Hyperkalemia · Patient complains of feeling hot · Skin is hot · Skin may feel dry · Headache and delirium · Seizures · Rapid, weak respiration · Tachycardia (rapid pulse) · Initial increase in systolic blood pressure, then a decrease with CHF that follows an increased temperature · Chest pain · Dyspnea (difficulty breathing) · Cardiac arrest · Increased WBC's as a result of physiologic stress Problem Causes Signs/Symptoms · Lactic acidosis from anaerobic metabolism and hemolysis · Hyperkalemia · Derangement of normal clotting mechanisms Crenation (Shriveling of red cells) Due to excess concentrate in dialysis · Water supply diminished or shut off · Conductivity limits not set properly · Proportioning unit not functioning properly · Failure of conductivity monitor · significant calibration error fouling of probe complete failure failure to set correct limits in manual system Bypass mechanism failure · Very dark red blood · Hypernatremia · Water flux out of patient from intracellular to extracellular (water movement is faster than sodium shift) · Intracellular dehydration and hyperosmolality – contraction in cell size · Gradient for influx of calcium occurs · Contracted or expanded extracellular volume · Headache · Nausea Power Failure · Overloading of electrical circuit · Local blackout · Machine accidentally unplugged · Stoppage of equipment · No lights until emergency generator kicks on · Unarmed or defective air detector · Careless IV administration · Empty IV bag · Large volume of air in venous line · Chest pain · Shortness of breath · Air in blood lines or loose connections · Air leak in the blood tubing or connections · Separation of blood lines · Very cold dialysate which contains large amounts of dissolved air that is released when warmed · · · - Coughing Cyanosis (blue-purple color of skin, lips, or nail beds) Visual disturbances double vision · · · · · blindness Confusion, restlessness, fear Slight paralysis of one side of the body Seizures Coma Possible cardiac arrest Air Embolism (air bubbles carried by the blood stream into a vessel small enough to be blocked by the bubble) - 11 - Problem Causes Signs/Symptoms Angina (chest pain) · Hypotension · Anemia – low hematocrit/hemoglobin · Anxiety · Chest pain · Rapid change in serum electrolytes, especially potassium · Hypotension · Volume excess · Low potassium level or rapid drop in potassium in conjunction with digitalis therapy · Myocardial infarction (blockage of a heart artery) · Slow or rapid and irregular pulse (heart rate) · Skipped or extra beats · Patient complains of “palpitations” · Electrolyte imbalance, especially hyperkalemia (too much potassium in the blood) · Arrhythmias · Myocardial infarction (hear attack) · Cardiac tamponade (fluid buildup in the pericardial sac surrounding the heart, preventing the heart from beating) · Large air embolism · Hemolysis (bursting of red cells) · Exsanguination (loss of all blood) · Hyperthermia (excessively high body temperature) · Absence of apical or carotid pulse · Rapid shifts in patient’s fluid volume · Painful muscle spasms (usually in the extremities – hands and feet) Arrhythmia/Dysrhythmia Cardiac Arrest · Lack of spontaneous respiration · Unresponsiveness · Abnormal heartbeat on cardiac monitor Muscle Cramps · Shift in blood chemistries, especially sodium · Fluid or electrolyte imbalance, especially depleted sodium · Hypokalemia (low potassium) - 12 - Problem Causes Signs/Symptoms Dialysis Disequilibrium Syndrome In the brain, there is a slower transfer of urea from the brain tissue to the blood, so fluid is drawn into the brain, causing swelling. · Too rapid a change in serum electrolytes, pH, or osmolarity · Hypertension · Occurs more often in acute renal failure or when BUN values are very high > 150 mg/dl) · Nausea and vomiting · · · · · · Headache Restlessness Convulsions Decreased level of consciousness Coma Death Fever and/or Chills · Infection · Infected access · Temperature over 990 · Redness, swelling or drainage from access · Patient feels cold · Shaking chills which lead to temperature elevation; chilling is involuntary · Temperature increase after dialysis is initiated, or temperature increase after termination of dialysis · Non-sterile technique · Contaminated dialyzer · Introduction of pyrogens (fever-producing substances) or endotoxin (byproducts of bacterial cell walls) via dialysate or inadequately reprocessed dialyzer - 13 - · Patient feels cold · Shaking chills which lead to a rise in temperature; chilling is involuntary · Hypotension · Temperature rise midway into the patient’s treatment Problem Causes Signs/Symptoms Headache · Fluid shifts · Dialysis disequilibrium – a slower transfer of urea occurs from the brain tissue to the blood, so fluid is drawn into the brain, causing swelling · Hypertension · Change in sodium level · Anxiety/nervous tension · Pain in the head or facial area · Error in initial heparin dose · Error in heparin infusion pump setting · Heparin pump malfunctioning · Unusual bleeding around needle sites (during treatment) · Prolonged bleeding from puncture sites post dialysis · Purpura (bleeding under the skin) noted if patient injured · Too many high K+ foods · Frequent infections, or excessive tissue breakdown · High serum glucose in diabetics · Bleeding, particularly gastrointestinal; or surgery · Sepsis (infection) · Hemolysis (red blood cells swell and rupture) or crenation (red cells shrink) · Recent blood transfusions · · · · · · Weakness Dizziness Nausea Vomiting Chest pain Arrhythmia · · · · · Numbness Tingling around mouth, tongue, hands, and feet Cramps in thighs Diarrhea Cardiac arrest Heparin Overdose Hyperkalemia (high potassium) - 14 - Problem Causes Signs/Symptoms Hypertension (high blood pressure) · Disequilibrium Syndrome · Fluid overload · Noncompliance with blood pressure medications · Rennin response (damaged kidneys may overproduce rennin, raising blood pressure) · Volume overload due to excess sodium or water · Increase in effective cardiac output during the course of dialysis · Increased peripheral vascular resistance (possible side effect of EPO) · Excessive ultrafiltraton – removal of too much fluid during treatment · Antihypertensive drugs · · · · Membrane Biocompatibility Problems Dizziness Headache Edema Nausea · · · · · Vomiting No symptoms (must monitor) Frequently asymptomatic (no symptoms) High blood pressure reading Gradual or sudden rise in blood pressure · Headache, blurring vision · · · · · · Anxiety Hypotension (low blood pressure) · · · · Low blood volume Low weight gain Dehydration (i.e., vomiting and diarrhea) Unstable cardiovascular status · Complement activation (immune reaction) caused by new cellulose membranes (common reaction in some patients) Nausea, vomiting, irritability May have no symptoms Rapid increase in hematocrit High systolic blood pressure reading Nervousness · Gradual or sudden decrease in blood pressure, possibly accompanied by dizziness, nausea and vomiting, perspiration or cold, clammy skin, tachycardia; loss of consciousness · An early symptom may be patients feeling quite wamr, fanning themselves · Yawning · Low blood pressure at beginning of treatment · Pallor, weakness · Feeling faint · Increase in apical pulse · Feeling anxious · Pruritis (itching) · Back pain · Hypotension - 15 - Problem First use syndrome Anaphylaxis reactions (immediate allergic reactions) Causes Signs/Symptoms · Thought to be the result of hypersensitivity to the ethylene oxide used to sterile some dialyzers · May be sterilant that remains in the potting material of the hollow fiber dialyzer · Acute bronchoconstriction (narrowing of breathing passages) · Vasodilatation (relaxation of blood vessels) · · - Hypotension Anaphylactic signs and symptoms anxiety cardiac output decreased flushing tightness in the chest respiratory diseases hives Nausea · · · · Pruritis (itching) Hypotension Disequilibrium Syndrome Pyrogenic reaction Influenza or intestinal virus · Nausea · Vomiting · Headache · Uremia · · · · · Dry skin Parathyroid dysfunction with calcium salt skin deposits Allergy to medication (i.e., heparin) or to dialyzer Calcium level in dialysate may be too high Increased calcium in water due to reverse osmosis failure - 16 - · · · · · Severe generalized itching on and off dialysis Reddened skin Crusting Increased phosphorus level Increased itching only when on dialysis Problem Recirculation (already dialyzed venous blood mixing with arterial blood in the patient’s access) Causes Signs/Symptoms · Needles are too close together – less than 2 inches apart · Darkening of blood – deoxygenation · “Black Blood Syndrome” · Increase of hematocrit · Increase in viscosity (thickness) of blood during dialysis · Reversed blood lines (arterial needle attached to venous blood line and venous needle attached to arterial blood line) · Inadequate flow from the access or poor positioning of the arterial needle · Poor arterial flow (arterial stricture, or narrowing); therefore, venous blood pulled through the arterial line · Arterial needle facing away from anastomosis (with an increased venous pressure) · Poor venous blood return - venous stricture - low flow through fistula - tourniquet above venous needle · Inadequate blood flow in the vascular access Restlessness and Insomnia · · · · · · Inadequate dialysis Missed treatment Depression Anxiety Hypercalcemia (too much calcium in the blood) Hyperkalemia (too much potassium in the blood) · · · · Fatigue, weakness and difficulty sleeping Anxious, depressed Loss of appetite High BUN Seizures · Dialysis Disequilibrium · Change in level of consciousness · Jerking movements of the arms and legs · Electrolyte · Change in level of consciousness · Delivery of improperly prepared dialysate · Change in level of consciousness · Jerking movements of the arms and legs - 17 - Problem Causes Signs/Symptoms Aneurysms True aneurysm A ballooning out of a weakened portion of the fistula vessel (active blood flows through the true aneurysm on puncture, aspirated blood is fresh. Occurs most commonly at the anastomosis in an AV fistula False Aneurysm (pseudoaneurysm) blood with false aneurysm is a collection of blood with no “communication” with blood in the active vessel; if punctured, dark, old, and possibly clotted blood would be aspirated · Infiltration (needle punctures through opposite vessel wall) of interior of vessel · Repeated puncture of vessel at same site; “one-site-it is” especially when proximal veins mature slowly or do not mature · Shearing between the walls of the vessel during venipuncture · Dilation (enlargement) of vessel wall a predominant sign · Bounding pulse in area of dilation · Area possibly more sensitive to venipuncture than remaining fistula Grafts: · Unsealed needle puncture site and hematoma formation · Unusual dilation of graft anywhere along its course · Repeated cannulation of same sites · Difficulty with venipuncture - 18 - Problem Clotting (Thrombosis) Causes Signs/Symptoms Any of the following can cause decreased blood flow through the anastomosis (surgical connection between artery and vein) and access. Any time there is decreased rate of flow, clotting can occur. 1. Hypotension - Recurrent orthostatic hypotension (a fall in blood pressure upon standing) - Severe chronic hypotension · Absence of bruit/thrill · Occasional patient complaints of pain at the arterial anastomosis prior to complete thrombosis · In a fistula, poor to no definition (dilation) of venous branches of fistula when tourniquet is applied to upper arm · Able to aspirate (withdraw) only black blood during venipuncture - Volume depletion in the vascular system 2. Prolonged pressure (compression of blood flow) on the vessel by: - Holding the extremity in one position for extended periods of time - Prolonged direct pressure on the vessel following needle removal - Use of constrictive clothing, bandages, or clamps Inadequate arterial blood flow 4. Stenosis (narrowing) of the Arterial anastomosis or any area of vein near the arterial anastomosis or venous end Poor venous return may be caused by narrowing of the vessel Development of a “pseudodiaphragm” (plaque formation that reduces blood flow) in a graft at the venous anastomosis; this membranous diaphragm can continue to narrow further until blood flow through the vessel is diminished to the point that clotting occurs. 7. Infection 8. Repeated venipuncture of the same sites particularly in a graft 9. Repeated infiltration compresses vessel Compression from hemorrhage into the tunnel of a graft Compression from a “pseudoaneurysm” Increase in venous pressure · Increased percent of recirculation - 19 - -Syndrome” Sudden decrease in · Arterial blood flow and pressure or increase in venous pressure when graft if compressed between two needles · Gradual increase in BUN and creatinine with no change in diet or muscle mass Problem Excessive Bleeding Infection (More serious in an AV graft than in an AV fistula; due to risk of disintegration of some synthetic materials and subsequent hemorrhage) Causes Signs/Symptoms Change in color of blood in art erial needle line when normal saline or dilute blood is introduced into circulation through the venous needle · Technical problems especially when inserting needles too close to, or into the anastomosis itself: - penetration of vessel walls at venipuncture - abrupt movement of the accessed limb - overloading of heparin - repeated venipunctures in the same sites will cause vessel weakness - Vessel weakness creating an aneurysm, which may precipitate excessive bleeding · Unusual bleeding during dialysis around puncture sites · Prolonged bleeding of access after dialysis · Break in a septic technique during cannulation or surgical procedure · Redness · Bacterial spreading from another infected site in the body · Poor hygiene and care of access arm · Swelling · Tenderness · Pain · Drainage · Any fluid collection around the graft · Fever with or without other signs if the infection is in the interior of the graft · Positive blood cultures · Early post-operative infection possibly extending the entire length of the graft because of the invasion of the tunnel · Fever and/or chills as hemodialysis treatment progresses - 20 - Problem Ischemia Steal syndrome (local and temporary loss of circulating blood due to obstruction of circulation to a limb) Causes Signs/Symptoms Fistula: · Affected limb colder distally (further from the body) than nonaffected limb and often paler If the anastomosis is too big, it can deprive the rest of the limb of an adequate amount of blood flow. Sometimes the blood flow will travel up an arm instead of down, for example. This problem may be worse in-patients with vascular, such as diabetes. · Cyanotic (blue) nail beds may be present Grafts: Normal arterial blood supply to distal extremity is shunted through the access, thus depriving the distal extremity of needed oxygenation; occurs most commonly in patients with poor distal circulation before surgery. · Pain in distal extremity (finger or toe) ranging from mild to severe and made worse or precipitated by dialysis is the classic symptom · Cold · Pale · Cyanotic finger or toe · Pain in distal extremity made worse by hemodialysis Needle Infiltration/Hematoma (The seepage of blood from a vessel into the surrounding soft tissue) · Improper venipuncture · Burning and tenderness at insertion site · Movement of the extremity after needle placement, which pushes the needle through the vessel · Needle slips out, or through the vessel, and into the surrounding tissue · Immediate swelling of the area · Hardness of the area · Pain · Discoloration · Discomfort for several days - 21 - Problem Poor blood flow (Inadequate blood flow and/or continuous collapsing when the blood pump is on) Causes Signs/Symptoms · Using an incorrect needle gauge · The blood in the tubing will appear foaming · Clotted needle or cannula · Since there is little or no blood flow through the dialyzer, the venous drip chamber may partially or totally collapse · Air will appear in the blood level in the venous drip chamber will be lower then normal (i.e. below the chamber filter) · Arterial line “jumping” · Clamp on line · Incorrect needle placement of the needle or cannula within the vessel. The needle bevel may be pushed up against the vessel wall. · Needle not in vessel · Vessel spasms · Improper blood pump speed · Clotted access · Kinking of the tubing · Failed access Hematoma formation (Swelling caused by blood leaking from vessel) · Penetration of both walls of the vessel by a cannula (most often is the underlying reason for a hematoma upon cannula insertion procedure) - 22 - · Pump segment collapse · High pre-pump negative pressure · Painful, hard, discolored swelling (caused by blood escaping from a vessel into surrounding tissue) Problem Causes Signs/Symptoms Kinking · Kink in blood lines · The catheter bending when the patient moves or lies on the same side as the catheter site · Sutures at the exit site may be kinking the catheter at the point of entry · Arterial line · Collapse of the arterial blood line (line will be “jumping” · The venous resistance will be low · Venous line · Increased venous resistance/pressure One-way obstruction · Should be suspected when a portion of the catheter can be flushed, but fluid cannot be withdrawn · Usually by tip malposition · Air bubbles in the tubing set – the blood is foamy · Incorrect placement of the catheter within the host vessel with side holes sucked up against vessel wall · Collapsed arterial blood line (i.e., pillow) · Venous drip chamber has collapsed or is set at a lower level than normal Poor blood flow · Drop in arterial pressure · Blood in arterial line will appear in foamy · Since there is little or no flow through the dialyzer the venous chamber may also partially or totally collapse · Air bubbles will appear in the blood tubing, and the blood level in the drip chamber may be lower than it normally should be, i.e. below the filter · Increased resistance to blood flow returning to the patient, which in turn may produce involuntary ultrafiltraton · Improper blood pump speed · Vessel spasm · Collapse in the arterial blood line · The resistance on the venous return will be low Thrombus - clot Formation may occur at the tip or in the tubing of either side of the catheter · Blood that was left to stagnate (sit) in the catheter between treatments · Inadequate heparinization of the catheter - 23 - · Unable to aspirate (withdraw) blood from either side of the catheter - 24 - MEDICATION We’ve discussed heparin as a medication given and used by both dialysis nurse and dialysis technicians. There are three other medications that are allowed to be given. Before giving any medication, you must first verify the doctor’s order. Check to see what the allowable dosage is and what time frames the medications can be given. Always look at the medication and verify it is the correct color and size. If it is not, call the pharmacy and/or check with the RN covering for you. Verify the medications are not expired. Checking the expiration date must occur three times: 1. When you initially pick up the medication. 2. Prior to putting the medication in the proper container. 3. Prior to discarding the package of medication. The three medications that you are allowed to give p.o. (by mouth) are acetaminophen, diphenhydramine, and quinine sulfate. Let’s take each one separately: Acetaminophen Most people know this drug as Tylenol. Few people are known to be allergic, but whenever you give a drug you must ask the patient if they are allergic to any medications. The dosage allowed to be given can be 375 mg to 1000 mg, only once during their treatment and ONLY if the patient had not taken any Tylenol up to four hours prior. If the patient states they took some Tylenol six hours before coming to dialysis, it would be okay to give the patient a dose during dialysis. It’s important to know adverse effects that medications can give. These can be found in the Facts and Comparisons Book located on each unit. The largest concern for Tylenol is for patients who have liver problems. Tylenol is cleared out of the body in the liver. Too much Tylenol can hurt a person’s liver and if the Tylenol is given to someone with a bad liver, it can make him or her worse. Diphenhydramine Most people know this drug as Benadryl. As discussed earlier, patients on dialysis often itch. Benadryl has been very helpful for many patients on dialysis. Benadryl does have a side effect of drowsiness. For some patients this is helpful in that they sleep during the HD treatment. Benadryl may only be given q4h (every four hours) like Tylenol. Therefore, it will be important to check with your patient when their last dose of this medication was taken. - 25 - Quinine Sulfate Quinine, although not used as often today, has been used very successfully for leg cramping. While the fluid is being removed during the dialysis process, many patients feel a drawling and/or pulling in their legs, much like a leg cramp. These leg cramps can be very painful for the patient. If someone not connected to a machine acquired a leg cramp, they would most likely stand up. Unfortunately, dialysis patients should not stand while receiving an HD treatment. Applying heat, pushing on the heel of the foot while the toes are pointing up can help. However, if these measures are not successful, quinine may be an option. Always check to verify the patient does have an order for quinine. Once a medication is given, it must be documented in the chart. Date and exact time given must be written down. Avoid touching the medication with your bare hand. Open the container into a medication cup or the patient’s hand. Do not use any p.o. medication that has fallen onto a dirty surface. And ALWAYS, ALWAYS, verify the medication dose AND if the patient is allergic. Drawing Medications into a syringe Follow specific unit procedures MSDS – Material Safety Data Sheets Fine each of tese sheets and comply with each units’ standards. - 26 - REUSE What is reuse? The term “reuse” in a dialysis unit refers to the artificial kidney, or dialyzer, being used more than one time or “reused.” The kidney is used on the patient, and then sent through a process that cleans then sterilizes it. Once sterilized, it can be used over and over until it is no longer effective. How does one know if a dialyzer is no longer effective? Each time a kidney is used, the volume inside is measured. Let’s say we fill the kidney with a fluid, and it can hold 100 cc. Once it is used small blood clots may fill some of the hollow fibers and restrict fluid from flowing into those places. Therefore, when you fill the kidney again, it may hold only 99cc of fluid. With each use, the volume will more than likely drop. Our standard is to reuse the kidney over and over until its fill volume has dropped 20% of the original volume, or in this case when the kidney can hold only 80 cc of fluid. Most units have a limit besides the fill volume of the kidney that will stop a kidney from being reused. Some dialysis units will not reuse a kidney more than 50 times, even though it can hold >80% of the original fill volume. The belief is the kidney will greatly lose its effectiveness after 50 uses. The role of the CNA-DT would include cleaning these dialyzers, processing the old blood out, then sterilizing and storing for future use. - 27 - REFERENCES 1- http://www.bloodpressure.com/article.cfm 2-http://www.onhealth.com/conditions/resource/conditions/item, 367.asp 3-http://www.uaa.alaska.edu/health/page8.html 4-http://www.aomc.org/HOD2/fitness/PointersOnPulse.html 5-http://www.bizmove.com/skills/m8g.htm 6-Amgen Manual 7http://rds.yahoo.com/_ylt=A9hnMifUz5pGHk4AlDajzbkF/SIG=125056tmu/EXP=1184637268 /**http%3A/222.flickr.com/photos/kdemetras/450972592 - 28 -