Download 6.2 Renal CP Management of Haemolysis on Haemodialysis

Renal: Management of Haemolysis on Haemodialysis _document No.
HNE Local Health District
Clinical Procedure
Renal: Management of Haemolysis on Haemodialysis
Sites where Clinical Procedure applies
Target audience:
Description
All HNE facilities where a patient undergoes haemodialysis
Nephrology clinical staff, who provide care to haemodialysis
patients.
This document comprises part of the clinical information
package for care for haemodialysis patients.
This Clinical Procedure applies to:
1. Adults
Yes
2. Children up to 16 years
No
3. Neonates – less than 29 days
No
Keywords
Renal Haemodialysis
Replaces Existing Procedure
Yes
Registration Number(s) and/or name and HNEH GandP 10_21
of Superseded Documents
Related Legislation, Australian Standards, NSW Health Policy Directive, NSQHS Standard/EQuIP
Criterion and/or other, HNE Health Documents, Professional Guidelines, Codes of Practice or Ethics:
 NSW Health Policy Directive 2007_079 Correct patient, Correct procedure, correct site
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf
 NSW Health Policy PD 2005_406 Consent to Medical Treatment
http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf
 NSW Health Policy Directive PD 2007_036 Infection Control Policy
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf

Greater Metropolitan Clinical Taskforce June 2008. Dialysis Water Pre-treatment for In-Centre and
Satellite Haemodialysis Units in NSW: A Set of Guidelines.
Prerequisites (if required)
Registered or Endorsed Enrolled Nurses who have been deemed
competent in the performance of haemodialysis
Procedure Note
This document reflects what is currently regarded as safe and
appropriate practice and requires mandatory compliance. If staff
believe that the procedure/s should not apply in a particular clinical
situation they must seek advice from their unit manager/delegate and
document the variance in the patients’ health record.
If this document needs to be utilised in a Non Nephrology Area please
liaise with the local Renal Service to ensure the appropriateness of the
information contained within the Clinical Procedure.
Renal Stream Leadership Group
Position responsible for the
procedure and authorised by
Procedure Contact Person
Contact Details
Date authorised
This Procedure contains
advice on therapeutics
Issue Date
Review due date
TRIM Number
Version 3
Tina Straker & Kelly Adams (Renal Coordinators)
Ph. 67769912 ph49 048800
No
October 2016
October 2013
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Renal: Management of Haemolysis on Haemodialysis _document No.
Consultation has occurred across the HNELHD Renal network utilising a group of identified
haemodialysis specialists as well as broader consultation with the general nephrology workforce,
nephrologists and the HNELHD Renal Leadership Group.
Note: Over time links in this document may cease working. Where this occurs please source the
document in the PPG Directory at: http://ppg.hne.health.nsw.gov.au/
RISK STATEMENT
This clinical procedure has been developed to provide guidance to staff and to ensure that the risks of harm
to patients and staff associated with performing Haemodialysis are identified and managed.
Staff may potentially be exposed to body substance and needle injury when carrying out this procedure.
Therefore strict Infection Control and Occupational Health and Safety rules should be followed when
attending this procedure; including wearing recommended Personal Protective equipment and following the
procedure steps.
Any unplanned event resulting in, or with the potential for, injury, damage or other loss to
patients/HCN/visitors as a result of this procedure must be reported through the Incident Information
Management System and managed in accordance with the Ministry of Health Policy Directive: Incident
Management PD2007_061. This would include unintended injury that results in disability, death or prolonged
hospital stay.
RISK CATEGORY: Clinical Care & Patient Safety
OUTCOMES
1
Haemolysis will be recognised early and appropriately managed to minimise poor outcomes
for the patient.
ABBREVIATIONS and GLOSSARY
Abbreviation/Word
Definition
IIMS
Incident Information Management System
LDH
Lactate Dehydrogenase
PREAMBLE
Haemolysis may be life threatening and requires early recognition and management.
Haemolysis is the rupturing of the red blood cells and can occur to the haemodialysis patient whilst
they are having a dialysis treatment.
Haemolysis can be caused by:
 Hypotonic or hypertonic dialysate
 Dialysate being over heated – temperature maintained above 42oc
 Water and dialysate concentrate being contaminated with chlorine / chloramines
 Inadequate rinsing of the dialyser
 Inappropriate use of hypotonic or hypertonic IV solution during the treatment
 High negative pressure in the extracorporeal circuit from kinking of the blood tube before
the blood pump, pre pump arterial pressure more negative than minus 250 mm Hg, blood
flow rate set too high for catheter or needle hole size
 Trauma to the red blood cell whilst passing through the circuit from too narrow blood tubing
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October 2013
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Renal: Management of Haemolysis on Haemodialysis _document No.
The risk to the patient is proportionate to the degree of haemolysis. In extreme cases the oxygen
carrying capacity of blood is compromised and cardiac and cerebral function is threatened.
Release of potassium from lysed cells carries the risk of hyperkalaemia and associated cardiac
events. Milder degrees of haemolysis contribute to anaemia and Erythropoietin resistance (Amato,
Hlebovy, King & Baltz Salai, 2008).
Signs and symptoms of haemolysis include: Chest, back or abdominal pain
 Dyspnoea
 Acute cerebral symptoms
 Cardio-respiratory distress
 Hypotension
 Translucent port wine or cherry – red coloured blood in the venous blood line
 Localized burning and pain in the vascular access return site
 Feeling hot ( if hyperthermic dialysate is the cause)
 Arrhythmias
 Acute decrease in haemoglobin and or haematocrit
 Hyperkalaemia
 Hypoxaemia
 Increased LDH, unconjugated bilirubin, decrease in serum haptoglobin.
(Amato, Hlebovy, King & Baltz Salai, 2008).
PROCEDURE
This procedure requires mandatory compliance.
Patient Preparation
It is mandatory to ensure that the patient has received appropriate information to provide informed
consent and, that patient identification, correct procedure and correct site process is completed
prior to any procedure.
Staff Preparation
It is mandatory for staff to follow relevant: “Five moments of hand hygiene”, infection control,
moving safely/safe manual handling, and documentation practices.
To avoid the possibility of haemolysis, the following Nursing Alerts are to be observed

Attention to the placement of the blood lines at the commencement of the dialysis treatment
and routine visual checks that the bloodlines are free from kinking during dialysis therapy

Monitor pre blood pump arterial pressures and maintain pressures above -250 mm Hg

Set appropriate blood flows for type and size of access and needle gauge (refer to needle
gauge guide for correct flow rates)

Administer hypertonic saline in limited divided doses into the venous chamber to ensure
dilution prior to delivery to patient to minimise the risk of haemolysis and sclerosing the
blood vessels

Observation at set-up and during haemodialysis to confirm appropriate dialysate
conductivity (13.5 – 14.5) and temperature readings on the dialysis machine

Preventative technical service procedures assuring proper function and calibration of
machine conductivity and thermostats

All water used for dialysis must be filtered through a carbon tank and testing of the water is
attended as policy Water for Dialysis – Central Water Plant Total Chlorine Testing HNEH
GandP 10_34
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October 2013
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Renal: Management of Haemolysis on Haemodialysis _document No.

All dialysis machines should be checked for recent chemical disinfection and a residual test
for chlorine is attended to ensure patient safety
Equipment Requirements

Alcohol based hand rub

Personal Protective Equipment (Apron, goggles, gloves)
Procedure Steps
1. Stop the blood pump, clamp venous line and arterial lines. Do not re-infuse haemolysed
blood
2. Place machine in bypass
3. Flush arterial and venous cannulas to ensure cannulas patency. Reassure the patient
4. Administer oxygen, remain with the patient, check vital signs and place on cardiac monitor
if possible. Watch for dysrthymias , hypotension and shortness of breath
5. Notify medical officer and rapid response team (or ambulance in stand-alone units) if
required
6. If necessary, replace fluid volume and / or blood volume if symptoms are severe via one of
the patent cannulas. Do not re-infuse haemolysed blood
7. Notify physician of the patient’s previously recorded haematocrit, current blood pressure,
signs and symptoms, estimate of the time of duration before haemolysis was detected and
an estimate of the amount of haemolysed blood which was returned to the patient
8. Take a sample of dialysate to send to pathology to check for osmality of dialysate solution –
looking for incorrect water to dialysate ratio
9. Save haemolysed blood lines for examination. Take 10 ml of blood from the dialysis lines
via the venous port for pathology testing. These tests should include full blood count,
electrolytes, haptoglobin and lactate dehydrogenase (LDH)
10. Upon the physicians’ orders, when corrective measures have been completed, using all
new dialysis equipment; prepare to recommence dialysis (this may include use of another
dialysis machine)
11. Re-adjust dialysis time, ultrafiltration and anticoagulation requirements. Anticoagulation
dose may require adjustment as the patient may have already received a substantial dose
during the initial dialysis session
12. After resuming dialysis, continue to monitor the patient observing for pulse rate
irregularities, dyspnoea, blood pressure and symptoms related to blood loss
13. One hour before the end of dialysis take blood from the arterial line and check haematocrit
(if offsite send to pathology as usual and ask for urgent result). Notify physician of result
14. Inform the patient that they may pass tea-coloured urine
15. Document in the progress notes all information pertinent to the haemolysis episode and
also the patient’s condition at the time of discharge from the unit
16. Complete IMMS
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APPENDICES
Nil
REFERENCES
Amato, R.L, Hlebvoy, D, King, B & Baltz Salai, P, Chapter 55, Complications of hemodialysis in
Counts, C.S (Ed). 2008. Core Curriculum for Nephrology Nursing (5th ed.), New Jersey: American
Nephrology Nurses Association, pg 710-712
Daugirdas, J.T., Blake,).G. & Ing, T.S. (Eds). (2007). Handbook of Dialysis (4th ed.), Philadelphia:
Lippincott Williams & Wilkens, pg. 185 & 186
FEEDBACK
Any feedback on this document should be sent to the Contact Officer listed on the front page.
Version 3
October 2013
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