Download Education For Emergency Staff Responders For Home Dialysis

Education For Emergency Staff Responders For
Home Dialysis Programs
Dialysis is a treatment for patients who have limited kidney function. We all
know that kidney failure means they don’t urinate like the rest of people do, but
probably never gave too much thought to the other ways this affects the lives of
the patient and family.
Sure, there are dialysis units and patients go there and have dialysis
treatments 3 days a week. We hear about this on television and may even know
someone who goes there. If the patient is able to drive him or herself to the unit
it really isn’t too difficult other than the cost of gasoline, we would think. If they
are elderly or can’t drive the family may rotate who is going to take this person to
the treatment and either shop while they are there, sit with them, or go home and
come back a few hours later. If no one is available from the family they look to
the social worker to help provide some type of assistance which can be anything
from a taxi to a wheelchair van, to ambulance transportation and again quite
costly. This is of course both directions 3 days a week back and forth to the unit
for the treatment.
Consider that the patient doesn’t feel well on the days of the treatment.
They remove anywhere from 1 pound to an ideal of 2-3 pounds or maybe as
much as 10-12 pounds at that 4 hour dialysis treatment. There are also chemical
shifts due to the removal of sodium, potassium, chloride, balancing of calcium,
phosphorus, magnesium, glucose along with the fluid removal. The patients may
experience nausea, cramping, dizziness, hypotension, or bleeding during
treatments. Heparin is used to prevent clotting of the blood in the dialyzer and
dosages need to be carefully adjusted for each patient to find the amount
required for that patient. Imbalance of phosphorus/calcium contributes to bone
density loss and osteoporosis is also a frequent problem for dialysis patients.
The dietitian and the dialysis staff reinforce that their new diet is limited in
potassium, sodium and phosphorus. If you take a look at the foods in the
grocery store you suddenly find every prepared food you can buy from soup to
sauces or cereal are loaded with salt and phosphorus and potassium. This
problem with the kidney usually is associated with high blood pressure so the
patients are usually on 1-3 blood pressure medications, probably not the
cheapest drugs ,if they work. Phosphorus isn’t cleared well by any dialysis
treatment so most patients are taking phosphate binders such as
renagel, $1.45 each, 3-15 daily dosage; fosrenal $2.14 each, 6-12 daily dosage,
or sensipar $.98 each, 1-4 daily dosage.
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The phosphate binders must be taken with or near meal time as they act
like a sponge to absorb the phosphorus and bind this in the intestines which
prevents it being absorbed in the blood stream. Try to eat a meal if you are a
little nauseated and then asked to take 2-6 tablets of a big pill that tastes like
chalk and also you are told you can only have 500cc of fluid to drink for that day.
Not very appealing. One soda is half of your fluid for the day, don’t forget the
liquid in the bowl of cereal or in that fruit is liquid too..
Many of these patients were providing the income to support the family,
maybe even carrying the insurance policy for the family. The insurance may have
a co payment required for each dialysis treatment. It is difficult to maintain many
types of employment on a part time basis, especially when you suddenly can’t
work on someone else’s idea of a schedule. Add the cost of the gasoline and the
co payment and then take away all or part of the earned income and then add
several new, expensive medications and this is a financial disaster for the patient
and family.
Hemodialysis requires some type of “access”, a way to take blood out of
your body to clean it, and return it back to the body. Our machines run on a
500cc/min blood flow with the ideal access but often times we have to work with
250-400cc blood flows and do the best we can.
The ideal “access” is a fistula and this is usually in the lower or upper arm,
preferable on the non dominant arm. Occasionally a fistula is on a leg although
I’ve only seen this a couple of times. A fistula is the patients own artery and vein
connected by a surgeon. It takes 6 weeks to 6 months for the arterial blood to
cause the vein to increase in size enough to insert a needle that is large enough
to run the hemodialysis treatment. We use 17 guage as the smallest needle and
preferable 15 guage needles for a developed fistula. The new fistulas are
cannulated by the more experienced staff members as they tend to be fragile and
if bruising occurs there can be pressure enough to clot the fistula or make it
difficult to cannulate the next time a patient comes for treatment.
A graft is a synthetic loop of material (dacron) which again connects a
patients arterial blood supply to a vein in another spot on either the arm or the leg
making a loop or sometimes a straight area with an enlarged spot that can be felt
(thrill) and needles can be inserted for blood flows. It is more likely for a graft to
become infected or clot since this is a synthetic material rather than the patients
own vein. As a patient, particularly a young working person, the body image is
altered when you look at this new graft or fistula in your arm or leg.
Never take blood pressures on an arm or leg that has a graft or a fistula
placed as this may cause bleeding, clot the graft, or harm the graft or the patient.
No one other than dialysis staff should draw bloods from these grafts and fistulas
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either. The access is an arterial/venous blood mixture and you may cause
damage or bleeding unless you know how to handle these needles.
In recent years many types of hemodialysis catheters have been used
successfully and for longer times than we were able to use in the past. A
catheter is usually inserted in the jugular vein and inside the body it leads into the
superior vena cava directly above the heart. The outside portion that you see is
in the upper chest wall or occasionally in the neck area. A temporary catheter
may be only sutured in but the more common catheters today are tunneled
catheters with one or two cuffs under the skin that allows the skin to eventually
adhere to the cuff to help prevent accidentally pulling the catheter out of the
chest. A catheter can also be in the groin area but this is usually when the
surgeon has been unable to use the upper body area for some reason.
A catheter has clamps on the lines that are kept closed except when in use,
and a cap is kept over the end. A catheter is prone to infection so it is handled
only with gloves/mask and good hand washing. The exit site is kept covered and
dressings are usually changed only at the dialysis units.
Most patients tend to remain on in center dialysis for those 3 day a week
treatment but today we have a short supply of chairs in the units and some
patients want to continue to have the lifestyle they were use to and spend time
with their family and not have this disease interrupt their life in this way.
Home dialysis treatments have been offered for many years. In the late
1970's peritoneal dialysis was initiated in the United States, I know home
hemodialysis was offered at that time also.
In the 1990's Robert Udall from Ontario, Canada started a home dialysis
program with computer monitoring of the patients so one observer could monitor
several patients at one time. This was started in the Saratoga Rubin Dialysis
Center in Saratoga Springs, NY in 1997. The patients complete a 6 week training
course at the center and then dialyze 6 nights weekly in their home, while
sleeping. Due to the observer monitoring the computer data there is no need for
a partner to be trained or present although many patients do have another
person in the home.
The overnight dialysis leaves daytime hours free for normal activities. The
dialysis process is done slowly over 7-8 hours so there are less chemical shifts
and less weight removal on any one treatment. There are less episodes of
cramping or hypotension related to the slower treatments. Patients have less
dietary restrictions and require less blood pressure medication and fewer
phosphate binders. Many patients are able to eliminate both of these and about
1/3 require the addition of phosphate to the dialysis bath to prevent depletion of
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the same phosphorus that required binders with in center hemodialysis
treatments.
Patients spend approximately 45 minutes preparing the machine for this
overnight treatment with equipment similar to what is used in the hemodialysis
center. They notify the observer when they start treatment and review what the
weight and fluid goal is for the treatment. The observer verifies the computer
connection and monitors the pressure readings that are significant to the safety
of the treatment.
If there is a problem with the treatment an alarm sounds to wake the
patient. The patient can usually resolve this alone within a minute. If the alarm is
not resolved within 2 minutes the observer will contact the patient to see if they
need assistance. There is a nurse and a technician on call if further assistance is
needed but most alarms are dealt with by the patient alone. IF the power is lost
in the home the patient is trained to return the blood by hand pumps and they
don’t complete that treatment. Since treatments are done on 6 nights a week it is
not a problem to miss one treatment. If there are prolonged power losses in the
area we arrange backup treatments at the Rubin Dialysis Center.
Emergency rescue squad numbers are kept for each home dialysis patient
and if the observer is unable to reach the patient by phone on a second attempt
for unsolved alarms the rescue squad will receive a request to go to the patients
home for assistance.
There have not been a lot of calls in the past 9 years but there have been
episodes of hypoglycemia, hypotension, myocardial infarction, which could have
been totally unrelated to the dialysis procedure. Bleeding is another common
dialysis problem that could require assistance if unable to stop this by normal
procedures. The catheters we currently use are unlikely to come out during
treatment due to the patients skin growing into the cuff, but there have been
known incidents of a catheter coming out of the patient, usually related to an
infection at the exit site.. If this were to occur direct pressure should be applied to
the area and they should be checked by the emergency room physician.
An air embolism is unlikely to occur due to the safety devices used by the
dialysis patients. During training patients are taught to lie on the left side with the
head lowered and feet elevated and call 911 if they suspect they may have given
themselves air. The machine has an air detector on the line returning blood to the
patient. Most of the patients using catheters use a special cap with a needleless
system that leaves an intact cap on the end of the catheter. This cap is left in
place during treatment. At this time many patients have proved to be safely using
the catheters and are allowed to remove this catheter cap and connect directly to
the blood line to increase dialysis efficiency by increasing the rate of the blood
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pump speed during treatment. A special locking box is used over a catheter
connections to prevent separation during treatment, whether the capping device
is used or the patient connects directly to the catheter line without a cap. A blue
locking box is kept in place over catheter connections to prevent blood line from
separating during treatment. This can be removed by pressing on the sides of the
locking box in opposite directions to release the connection.
If you do rescue a patient with a catheter please remember to do this while
wearing a mask and gloves to prevent infection of the patient . With universal
precautions gloves should be worn with contact with any access to any type of
treatment. Rescue of a patient using a catheter would require clamping of both
catheter lines and the blood lines (4 clamps) and separating the blood lines from
the catheter lines by turning the connection at the red or blue portion in a
counterclockwise direction. If no cap is present on the end of the catheter a
syringe should be placed on the connection for transport to the hospital. This will
prevent accidental air embolism or contamination of the catheter.
Initially all the patients were using a catheter for hemodialysis access. Due
to the problem with infection and blockage of the subclavian vessels related to
the catheter usage we have progressed to using blunt needles on overnight
treatments. In more recent years we have also used a single needle which may
be a sharp or a blunt tip on the needle. We have special taping devices used for
safety which will be shown to you at this time. The most commonly used tape at
this time is made with toupee glue and sticks securely. The wings of the needle
are butterfly taped, wrapped again with another tape usually with lines placed in
a loop to prevent accidental removal of the needle lines.
In a rescue in a patient’s home the procedure is going to be the same as
used with a catheter patient. There are clamps on the blood lines and clamps on
the fistula needle lines. These should all be clamped to prevent blood loss. (4
clamps). You are not responsible for the equipment although our staff could tell
you how to turn the machine off if the patient is alone in the home. The 4 clamps
are closed and the lines are separated. The connections will be taped on fistula
needle connections. You separate this by turning the connection counter
clockwise at the red or blue connection between the needle and the blood line.
You will have an access for medications if they are needed and trained staff are
available to give the medications. A syringe should be kept on any open end of
any fistula needle to prevent contamination or blood loss.
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During the last year we have embarked on a newer form of home dialysis
called the Nxstage home dialysis program. The machine is easier for the patient
to prepare. The preparation time is reduced to about 30 minutes. It only weighs
70 lbs, it is more portable making it easier for the patient to travel. There isn’t an
overnight program at this time. The patients doing this program have a partner in
the home with them. Most patients are dialyzing during the evening hours but
that does vary from one patient to another. The access for this dialysis may be a
fistula with needles or a catheter connection to the machine. The fistula patients
may have sharp needles or blunt needles. The wings are green on a blunt
needle and blue on a sharp needle, otherwise they look exactly the same.
The patients are running 6 treatments weekly and the length varies from
one patient to another by their medical needs usually between 2-4 hours in
length. Due to the shorter length of treatment the fluid goals are removed more
quickly so they are somewhat more likely to have cramping or hypotension than
on the overnight program, but less likely than when the patient dialyzed 3 days
weekly in the dialysis unit. The emergency procedure would be the same, close 4
clamps and disconnect the patient by turning the red or blue connections counter
clockwise to separate blood line from the needle lines.
Another form of home dialysis is peritoneal dialysis. The peritoneal dialysis
access is a tunneled catheter with 2 cuffs under the skin which allow skin to grow
into the cuff to seal the area. Peritoneal dialysis is done by infusing a specially
prepared fluid into the abdomen rather than drawing blood from the patient. The
abdominal wall has a membrane called the peritoneal membrane that allows
exchanges of chemicals (sodium, bun, creatinine, potassium, ca, mg, cl, glucose)
and this accomplishes dialysis in a different way than what is done in the unit.
This catheter is also handled only with a mask, careful hand washing and staff
wears sterile gloves to prevent an infection.
These treatments are performed daily and causes less episodes of
hypotension or cramping.
The catheter is surgically placed in the lower abdomen which heals for 1
month before being used. This healing time helps prevent accidental movement
of the catheter cuffs or leaking around the catheter in the exit site area. Patients
are trained for 1-2 weeks to maintain a sterile treatment and prevent infections.
In this modality the patient could do 4 separate exchanges of fluid manually
during daytime hours, usually divided to 4-5 hours between the exchanges.
(continuous ambulatory peritoneal dialysis). They also could be trained to an
overnight machine which does the treatment exchanges automatically during the
night time hours (continuous cycler peritoneal dialysis).
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If you were called to a home with a peritoneal dialysis patient in an
emergency there is a slide clamp on the line which should be showing a red dot
for closed position to disconnect from the machine. Some connections may have
a roller clamp that resembles an iv roller clamp and closed is in the tightened
position. There is a snap disconnection which is a hard ridge of plastic on the
tubing line near the patient connection. There should always be a clamp on the
patient side before disconnection from the tubing. The lines usually have a blue
clamp that presses closed for safety.
In any type of rescue where a patient is connected to any dialysis treatment
remember to close the clamps on the tubing before disconnection occurs. Adhere
to universal precautions and wear mask and gloves for both your protection and
the protection of the patient from infection. Separate the access tubing from the
machine tubing. In the case of no machine attached (ambulatory peritoneal
dialysis) you could just bring the bags you find with you to the emergency room
for staff to disconnect (optional). If our staff has called you to this home we will
be able to give you directions on rescue procedures and please feel free to ask
for assistance.
There are usually blue emergency clamps kept around any home dialysis
patient setting and these can always be applied over the line on either side of a
disconnection spot for any type of modality for dialysis.
In closing for any patient rescue be sure to close the clamps on both sides
of any connection. Wear a mask and gloves while separating the connection.
Attach a syringe to any open needle or catheter lines to prevent bleeding,
infection or air embolism. Be careful of pressure to a needle site while moving the
patient. Do not attempt to remove the needles for transportation as this patient is
heparinized and will take some time for the site to clot when the needle is
removed. Transport the patient to the hospital for follow-up care.
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