Dialysis

Renal Disease and Dialysis

Objectives

CKD

Dialysis

Chronic Kidney Disease

DIALYSIS

HD, PD, CAPD

Common Diagnosis

CKD (ESRD) secondary to hypertensive

nephropathy

Acute gastroenteritis

AKI, Acute gastroenteritis

CKD (ESRD) secondary to chronic

glomerulonephritis

CKD(ESRD) secondary to Diabetic

nephropathy

Indications

End-stage renal failure – GFR less than 5

ml/min( dialysis or renal transplant is

needed).

Contd… Clinical

Fluid overload not responding to diuretics. Uremic convulsion Persistent dyspnea, vomiting and restlessness. Signs of pericarditis, pericardial effusion, pericardial

friction rub. Biochemical

Chemical ARF CRF Normal

Urea >35 mmol/L >40 mmol/L 2.5-6.5 Creatinine >12-14 mg/dl >12-14 mg/dl 0.6-1.3 Potassium >6.5 Meq/L >6.5 Meq/L 3.5-5.5 PH <7.1 <7. 1 7.35-

7.45

Hours for hemodialysis

Hemodialysis usually is done three times a

week.

Each treatment lasts from 2 to 4 hours. During

treatment, patient can read, write, sleep, talk, or

watch TV.

http://www.medicinenet.com/script/main/art.asp?articlekey=6177

Hemodialysis

Semipermeable membrane

Solute removal via passive diffusion

◦ Inversely proportional to the size (ie effective

removal of K, urea, C; not of PO4)

Ultrafiltration

use of hydrostatic pressure gradient to

induce convection (filtration of water)

solvent drag (pulls dissolved solutes)

across

removal of excess fluid

CVVH

highly permeable membrane

fluid and solute removal via ultrafiltration

filtrate is discarded

replacement fluid is infused similar to

plasma (but no K, urea, Cr, PO4)

used in ICU, runs 12-24h, through double

lumen catheter

less drastic fluid shifts

Preparations for Dialysis

Articles needed for dialysis

i. Arteriovenous fistula : common venous access for HD. Usually radial artery and cephalic vein are anastomosed.

Dialyser set

Arteriovenous set

Fistula needle

Haemodialysis fluid with bicarbonate powder (5 litre)

IV set

…

Inj. 25% Dextrose : If associated with Diabetes,

Diabetic Uropathy , Diabetic Nephropathy.

Inj. Normal Saline(500 ml)

Inj Avil

Inj Heparin

Syringes : 20, 10 & 5 cc.

…

ii. Via Femoral (It is done through through femoral

vein

Dialyser set

Arteriovenous set

Femoral Catheter

Guide Wire Straight tip (70cm)

Haemodialysis fluid with Bicarbonate powder (

5litre)

IV canula

…

IV set

Inj. 25 % Dextrose

Inj 2% Xylocaine

Inj. Normal Saline 500ml

Inj. Avil

Inj. Heparin

Syringes : 20, 10 , 5 cc.

Chemicals Used In Dialysis

Sodium Hypochlorite

Hydrogen Peroxide

Formaldehyde

Part A and part B

i. Part A

Concentrate contains :

Sodium Chloride : 173.65 gm/l

Potassium Chloride : 5.06 gm/l

Calcium Chloride : 8.75 gm/l

Magnesium Chloride : 5.18 gm/l

Glacial Acetic Acid : 8.17gm/l

…

ii. Part B

Sodium Bicarbonate : 626gm

Sodium Chloride : 221 gm

(mixed with 9 litres of Reverse Osmosis water)

Medication used during dialysis

Heparin :6000 IU

Side Effects of Heparin : Pruritus, Allergy

,Osteoporosis, Hyperlipidemia,

Thrombocytopenia

Avil : 1 Ampoule (each ml contains 22.75 mg)

Hydrocortisone :1vial = 100 mg

25% dextrose:

Epofit

Heparin free case

Periodic saline rinse

Every 15-30 minutes , rinse the dialyser rapidly

with 100-250 ml of saline while occluding the

blood inlet line.

The purpose of the periodic rinsing is to allow

inspection of a hollow-fiber dialyser for

evidence of clotting.

Hypoglycemia: It can develop in diabetic patient

treated with either hemodialysis or peritoneal

dialysis and is usually due to reduced insulin

catabolism and to reduce intake and absorption

of food.

In diabetic patients hemodialysis solution should

always contain about 200mg/dl glucose if not

added then severe hypoglycemia during or soon

after hemodialysis can result.

Investigation

Haemoglobin :15 days

Urea, creatinine, Na+, K+ : 1 month

Serology : 2 months

Range of

conductivity:14.7mMho13.2mMho

Normal range of TMP: -100 to 500

The usual flow rate for adult patient is

200-350 ml/min

Financial

Amount of 5 lakhs is provided by the

government for dialysis

Complications Infection

Fever and chills

Catheter clotting

Hypotension

Muscle cramps

Septicemia

Hepatits C

Prognosis(Life expectancy)

2-4 years in haemodialysis

9-10 years in CAPD

Disequilibrium Syndrome : It is the set of

systemic and neurologic symptoms often

associated with characteristic EEG findings that

can occur either during or soon after dialysis .

Early manifestation:nausea ,vomiting

,restlesssness ,headache

Serious manifestation : coma, seizure

Care of vascular access

Check access before each treatment.

Keep access clean at all times. Do not use cream or

lotion over the site.

Use access site only for dialysis.

Be careful not to bump or cut access.

Don’t put a blood pressure cuff on access arm.

Remove jewellary or tight clothes over access site.

Don’t sleep with access arm under your head or

body.

Don’t lift heavy objects or put pressure on access

arm.

Check the pulse in your access every day.

Diet Pattern

Fluid restriction: total intake<1 lit/day in oliguric

ARF and total intake <urine output + extra

renal loss

Total caloric intake– 35~ 50 kcal/kg/day

to avoid catabolism

Salt restriction– 2~4 g/day

Potassium intake– 40 meq/day

Phosphorus intake– 800 mg/day

Daily protein intake of between 0.60 and

0.75gm/kg/day.

The normal level of potassium intake is 3.5-5.0

mEq/l.

2-3g/day of sodium is allowed in CKD patient.

Phosphorus consumption for normal people as well

as people with CKD for non dialysis is 2.7-4.6mg/dl.

For CKD dialysis patients the target range is 3.5-

5.5mg/dl.

Dialyzer Re-use

1. Reprocessing technique : The major steps in

dialyzer reuse are rinsing , cleaning,

measurement of dialyzer performance,

disinfection/sterilization and germicide

removal.

a) Rinsing and reverse ultrafiltration

b) Cleaning : Sodium hypochlorite

c) Other cleaning agents : Hydrogen

peroxide,formalin

Nursing consideration

Pre Haemodialysis:

Correct identification of patient, using hospital

number and date of birth

Blood pressure, pulse and temperature

Weight

Blood glucose if diabetic

Observe / assess patient for any other problems

or needs

Observe access site – neckline / fistula / graft

Assess A-B-C

Ambulation, access,

Breathing

Cardiovascular status

Changes

Post Haemodialysis:

After termination of dialysis, record Blood

pressure, pulse and temperature

Blood glucose if diabetic

Weight – assist to scales if necessary

Observe access site to ensure no further

bleeding / dressing secure

Peritoneal Dialysis

peritoneal membrane = partially permeable membrane

dextrose dialysate

diffusion and osmosis until equilibrium

3-10 dwells per night with 2-2.5 L per dwell

Indications for Dialysis

Acidosis

Electrolytes

Ingestions

Overload

Uremia

Access

Arteriovenous fistula (AVF)

Graft

Tunneled catheter

Arteriovenous Fistula

◦ Highest patency

◦ Lowest risk of infection

◦ Low risk of thrombus

◦ Maturation time (3-4mo)

◦ Steal syndrome (poor

blood supply to the rest

of the limb)

◦ Aneurysm formation

Arteriovenous Graft

Easier to create

Maturation time 3-6 weeks

Poor patency (often requires thrombectomy or angioplasty)

Infection

Aneurysms

Steal syndrome

Tunneled Catheter

Immediate use

Bridge to AVF/AVG

Poor flow (decreased HD efficiency)

High infection risk

Venous stenosis

Thrombosis

Dialysis Rx:

Time: 2-5 hours

Bath

Blood flow rate: 400-450cc/min

Dialysate flow rate: 500-800cc/min

Anticoagulant

Additives:

◦ Anemia (EPO, blood)

◦ Bone metabolism (vit D, calcitriol, etc)

◦ Meds (antibiotics)

Dialysate Bath

Common Admissions on Eckel

Complications of missed HD

◦ SOB from fluid overload

◦ HTN crisis

◦ Hyperkalemia

Line infections

Access issues

And everything else…

Eckel Pearls: presentation

75 yo AAM with ESRD 2/2 DM (HD MWF

via RUE AVF, at CDC East, nephrologist

Dr. Wish, dry weight 82kg, oligouric)

Eckel Pearls: history

how did the last HD session go?

complications since being started on HD?

◦ infections?

◦ multiple access points?

medically compliant?

get run sheets from dialysis center

Eckel Pearls: physical exam

Vitals: no BP in the arm of the access

Volume status

Access:

◦ Infection?

◦ Aneurysms

◦ Bruits/thrills

Page 1

RN LK50: OMG’s K is 3.1. Can we

replete?

•Had dialysis 3rd shift. Finished 2hrs ago

Labs in ESRD

Get labs before or 4h after HD

Only the H/H is accurate

Floor RNs can’t use HD lines

Can ask to have cultures drawn at HD

from the line

Page 2

RN LK20: New admit AMS on floor. Hard to arouse. Please eval

ED presentation with abd pain

Workup initiated since there are no beds…

Pain meds: morphine 1mg, then 1mg, then 2 mg, then 3mg IVP

Sent to the floor

Medications in ESRD

Antibiotics

◦ Renally dose

◦ Loading dose, then maintenance dose

No lovenox dvt ppx, use heparin

No morphine

◦ Hepatic metabolism – but active metabolites

◦ Limit the other opioids

Dilaudid: hepatic metabolism – but metabolites can cause neuroexcitiation

constipation/GERD : avoid magnesium/phosphate containing agents

Page 3

RN: new admit OK. Called wound care for

leg.

After lunch you walk on over to the patient

room. ESRD admitted for access.

OK is doing ok. Vitals stable. Comfortable.

Calciphylaxis

Calcinosis cutis

Page 4

RN LK20: Code white, WAA is hypoxic, 83% on RA. Now 92% on VM.

Acutely SOB. Looks uncomfortable.

Your co-NF points that one leg is bigger than the other.

You ask, “have you had a blood clot before?”

WAA nods yes.

Hmmm….amongst other things, CTPE?

Imaging in CKD

Avoid contrast in CKD patients

If you have to, prep

◦ volume expansion: isotonic IVFs

3 cc/kg x 1h before

1cc/kg x 6h after

◦ ? alkalinization: sodium bicarbonate

◦ ? acetylcysteine

◦ radiology can give you the protocol

(treat empirically)

Imaging in ESRD

CT with contrast is ok

MRI with gadolinium is NOT:

◦ Nephrogenic Systemic Fibrosis (NSF)

◦ IF you must: HD x 3 over 3 consecutive days,

with the first right after

Page 5

RN LK20: Lost access on GRR. Can you order a PICC?

Finally, an easy question.

CKD. Sure, why not?

Access in CKD

Avoid PICC/midlines in CKD stage 4-5

Try to preserve access

Try for the feet/EJ

But if you need to, order a midline

PCP should refer CKD stage IV to nephrologists in anticipation of HD

Don’t treat them lightly

The end.

Dialysis Patients at Risk

for Infection

Why are Dialysis Patients at Risk for

Infection?

◦ Frequent use of catheters or insertion of needles

to access the bloodstream

◦ Weakened immune systems

◦ Frequent hospital stays and surgery

Dialysis patients are at risk of getting hepatitis B

and C infections and bloodstream infections

◦ Hepatitis B and C are bloodborne

viral infections that can cause chronic

(life-long) disease involving

inflammation (swelling) of the liver Hepatitis B and C viruses can live on

surfaces and be spread without visible blood

◦ A bloodstream infection is a serious infection that can

occur when bacteria or other germs get into the blood

One way bacteria can enter the bloodstream is through a vascular

access (catheter, fistula, or graft)

Infections in Dialysis Patients

• Advise patients to inform you if they notice any of the following

possible signs of infection:

– Fever

– The access site is:

• Swollen (bulging),

• red,

• warm, or

• has pus

– Severe pain at the access site

Remember: infections of the vascular

access site can be life threatening

How to Recognize an Infection

Bloodstream infections are a dangerous complication of

dialysis

1 in 4 patients who get a

bloodstream infection caused by

S. aureus (staph) bacteria can face

complications such as:

◦ Endocarditis (infected heart valve)

◦ Osteomyelitis (infected bone)

Total costs for each infection can be more than $20,000

Bloodstream infections can cause sepsis (a potentially deadly

condition)

Up to 1 in 5 patients with an infection die within 12 weeks

Infections in Dialysis Patients

Basic Steps in Fistula/Graft Care

Cannulation Procedure:

1. Wash the site

2. Perform hand hygiene

3. Put on a new, clean pair of gloves

4. Wear proper face protection

5. Apply skin antiseptic and allow it

to dry

6. Insert needle using aseptic

technique

7. Remove gloves and perform hand

hygiene

Aseptic technique means taking great care to not contaminate the fistula

or graft site before or during the cannulation or decannulation procedure

Photo provided by Stephanie Booth, used with permission

Basic Steps in Catheter Care

Catheter Connection Procedure:




4. Apply antiseptic to catheter hub and allow it to dry

5. Connect the catheter to blood lines using aseptic technique

6. Unclamp the catheter

7. Remove gloves and perform hand hygiene

Basic Steps in Catheter Care

Catheter Disconnection Procedure:




4. Disconnect the catheter from blood lines using aseptic technique

5. Apply antiseptic to catheter hub and allow it to dry

6. Replace caps using aseptic technique

7. Make sure the catheter remains clamped

8. Remove gloves and perform hand hygiene

Catheter Exit Site Care



3. Wear a face mask if required

4. Apply antiseptic to catheter exit

site and allow it to dry

5. Apply antimicrobial ointment

6. Apply clean dressing to exit site

7. Remove gloves and perform hand

hygiene


Separate Clean Areas from Contaminated

Areas

• Clean areas should be used for the

preparation, handling and storage of

medications and unused supplies and equipment

– Your center should have clean medication and

clean supply areas

• Contaminated areas are where used

supplies and equipment are handled

• Do not handle or store medications or clean

supplies in the same area as where used

equipment or blood samples are handled

Remember: Treatment stations are contaminated areas!

Clean area


Dedicate Supplies to a Single Patient

• Any item taken to a patient’s dialysis

station could become contaminated

• Items taken into the dialysis station should either be:

– Disposed of, or

– Cleaned and disinfected before being taken to a common clean area or used on another patient

• Unused medications or supplies taken to the patient’s station should not be returned to a common clean area (e.g., medication vials, syringes, alcohol swabs)

Photo provided by Marshia Coe and Teresa Hoosier, used with permission

Safe Use of Medication Vials

• Prepare all individual patient doses in a

clean area away from dialysis stations

• Prepare doses as close as possible to the

time of use

• Do not carry medications from station

to station

• Do not prepare or store medications at

patient stations

• CDC recommends that dialysis facilities:

– Use single-dose vials whenever possible and

dispose of them immediately after use

Guidelines for Carrying Medications

Do not use the same medication cart to deliver

medications to multiple patients

Do not carry medication vials, syringes, alcohol swabs, or

supplies in pockets

Be sure to prepare the medication in a clean area away

from the patient station and bring it to the patient station

for that patient only at the time of use

Cleaning and disinfection reduce the risk of spreading an

infection

Cleaning is done using cleaning detergent,

water and friction, and is intended to

remove blood, body fluids, and other

contaminants from objects and surfaces

Disinfection is a process that kills many

or all remaining infection-causing

germs on clean objects and surfaces

◦ Use an EPA-registered hospital disinfectant

◦ Follow label instructions for proper dilution

Wear gloves during the cleaning/disinfection process

Cleaning and Disinfecting the

Dialysis Station

All equipment and surfaces are considered to be

contaminated after a dialysis session and therefore must be

disinfected

After the patient leaves the station,

disinfect the dialysis station

(including chairs, trays, countertops,

and machines) after each patient

treatment

◦ Wipe all surfaces

◦ Surfaces should be wet with disinfectant and allowed to air dry

◦ Give special attention to cleaning control panels on the dialysis

machines and other commonly touched surfaces

◦ Empty and disinfect all surfaces of prime waste containers

Disinfecting the Dialysis Station


Safe Handling of Dialyzers and

Blood Tubing

• Before removing or transporting used

dialyzers and blood tubing, cap dialyzer

ports and clamp tubing

• Place all used dialyzers and tubing in

leak-proof containers for transport

from station to reprocessing or

disposal area

• If dialyzers are reused, follow

published methods (e.g., AAMI

standards) for reprocessing

AAMI is the Association for the Advancement of Medical

Instrumentation


Conclusion

Infections that patients can get while receiving dialysis are

serious and preventable!

Healthcare workers like you following infection control

precautions and other safe care practices are the key to

prevention

Infection prevention is everyone’s responsibility

Dialysis

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