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Dialysis

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Dialysis

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Dialysis

  1. 1. Renal Disease and Dialysis
  2. 2. Objectives  CKD  Dialysis
  3. 3. Chronic Kidney Disease
  4. 4. DIALYSIS HD, PD, CAPD
  5. 5. 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
  6. 6. Indications End-stage renal failure – GFR less than 5 ml/min( dialysis or renal transplant is needed).
  7. 7. 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
  8. 8. 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.
  9. 9. Hemodialysis  Semipermeable membrane  Solute removal via passive diffusion ◦ Inversely proportional to the size (ie effective removal of K, urea, C; not of PO4)
  10. 10. Ultrafiltration  use of hydrostatic pressure gradient to induce convection (filtration of water)  solvent drag (pulls dissolved solutes) across  removal of excess fluid
  11. 11. 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
  12. 12. 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
  13. 13. …  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.
  14. 14. … 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
  15. 15. …  IV set  Inj. 25 % Dextrose  Inj 2% Xylocaine  Inj. Normal Saline 500ml  Inj.Avil  Inj. Heparin  Syringes : 20, 10 , 5 cc.
  16. 16. Chemicals Used In Dialysis Sodium Hypochlorite Hydrogen Peroxide Formaldehyde
  17. 17. 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
  18. 18. … ii. Part B  Sodium Bicarbonate : 626gm  Sodium Chloride : 221 gm (mixed with 9 litres of Reverse Osmosis water)
  19. 19. 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
  20. 20. 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.
  21. 21. 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.
  22. 22.  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.
  23. 23. Investigation  Haemoglobin :15 days  Urea, creatinine,Na+, K+ : 1 month  Serology : 2 months
  24. 24.  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
  25. 25. Financial  Amount of 5 lakhs is provided by the government for dialysis
  26. 26. Complications  Infection  Fever and chills  Catheter clotting  Hypotension  Muscle cramps  Septicemia  Hepatits C
  27. 27. Prognosis(Life expectancy)  2-4 years in haemodialysis  9-10 years in CAPD
  28. 28.  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
  29. 29. 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.
  30. 30. 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
  31. 31.  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.
  32. 32. 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
  33. 33. 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
  34. 34. Assess A-B-C  Ambulation,access,  Breathing  Cardiovascular status  Changes
  35. 35. 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
  36. 36. 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
  37. 37. Indications for Dialysis  Acidosis  Electrolytes  Ingestions  Overload  Uremia
  38. 38. Access  Arteriovenous fistula (AVF)  Graft  Tunneled catheter
  39. 39. 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
  40. 40. Arteriovenous Graft  Easier to create  Maturation time 3-6 weeks  Poor patency (often requires thrombectomy or angioplasty)  Infection  Aneurysms  Steal syndrome
  41. 41. Tunneled Catheter  Immediate use  Bridge to AVF/AVG  Poor flow (decreased HD efficiency)  High infection risk  Venous stenosis  Thrombosis
  42. 42. 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)
  43. 43. Dialysate Bath
  44. 44. Common Admissions on Eckel  Complications of missed HD ◦ SOB from fluid overload ◦ HTN crisis ◦ Hyperkalemia  Line infections  Access issues  And everything else…
  45. 45. 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)
  46. 46. 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
  47. 47. Eckel Pearls: physical exam  Vitals: no BP in the arm of the access  Volume status  Access: ◦ Infection? ◦ Aneurysms ◦ Bruits/thrills
  48. 48. Page 1  RN LK50: OMG’s K is 3.1. Can we replete? •Had dialysis 3rd shift. Finished 2hrs ago
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. 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.
  53. 53. Calciphylaxis Calcinosis cutis
  54. 54. Page 4  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?
  55. 55. 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)
  56. 56. 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
  57. 57. Page 5  RN LK20: Lost access on GRR. Can you order a PICC?  Finally, an easy question.  CKD. Sure, why not?
  58. 58. 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
  59. 59. Don’t treat them lightly
  60. 60. The end.
  61. 61. Dialysis Patients at Risk for Infection
  62. 62. 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
  63. 63.  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
  64. 64. • 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
  65. 65.  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
  66. 66. 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
  67. 67. Basic Steps in Catheter Care Catheter Connection Procedure: 1. Perform hand hygiene 2. Put on a new, clean pair of gloves 3. Wear proper face protection 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
  68. 68. Basic Steps in Catheter Care Catheter Disconnection Procedure: 1. Perform hand hygiene 2. Put on a new, clean pair of gloves 3. Wear proper face protection 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
  69. 69. Catheter Exit Site Care 1. Perform hand hygiene 2. Put on a new, clean pair of gloves 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 Photo provided by Stephanie Booth, used with permission
  70. 70. 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 Photo provided by Stephanie Booth, used with permission
  71. 71. 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
  72. 72. 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
  73. 73. 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
  74. 74.  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
  75. 75.  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 Photo provided by Stephanie Booth, used with permission
  76. 76. 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 Photo provided by Stephanie Booth, used with permission
  77. 77. 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

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