Dialysis

Objectives
 CKD
 Dialysis

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
watchTV.

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
 GuideWire 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.

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)

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

 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

 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

 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

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

 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

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 MedicationVials
• 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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