DIALYSIS is a procedure that is given to people who have lost a kidney, have kidney problems due to birth defects, or who have kidney failure. A mechanical means of removing nitrogenous waste from the blood by imitating the function of the nephrons. Strict aseptic care is mandatory for dialysis clients.
TYPES OF DIALYSIS hemodialysis
peritoneal dialysis.
hemodialysis
A mechanical means of removing nitrogenous waste and excess fluid from the blood by imitating the function of the nephrons via semi permeable membrane.
ACCESS FOR HEMODIALYSIS Catheters - jugular vein - femoral vein
AV Fistula = anastomosis
ACCESS HEMODIALYSIS 3x/week total of 9 to 12 hours
Dialysis orders based on body size, renal function, dietary intake, concurrent illness
Steps in Hemodialysis Process Priming Recirculation -15 minutes. Dialysis process 4 hours Termination MOST COMMON HEMODIALYSIS COMPLICATIONS 1. Hypotension 20 - 30% 2. Cramps 5 - 20% 3. Nausea / Vomiting 5 - 15% 4. Headache 5% 5. Chest pain 2 - 5% 6. Back pain 2 - 5% 7. Chills 1% Definition: * Sudden drop in systolic BP to < 90 mmHg * > 30 mmHg drop in MAP * > 30 mmHg drop in systolic BP + symptoms INTRADIALYTIC HYPOTENSION [IDH] SYMPTOMS OF HYPOTENSION 1. Nausea / Vomiting 2. Cramps 3. Light headedness / dizziness 4. For some, none INTRADIALYTIC HYPOTENSION A. Early B. Late
1. Dialyzer volume 1. High UFR 2. Medications a. high interdialytic weight gain 3. Sepsis b. too low dry weight 4. Pericardial disease 2. Acetate dialysis 3. Autonomic neuropathy 4. Heart disease
Subgroup analysis of patients with very frequent IDH Co morbidities: 1. Old age 2. DM 3. Autonomic neuropathy 4. Florid uremia 5. Pericardial disease 6. Cardiac disease a) systolic dysfxn b) diastolic dysfxn c) arrhythmia VOLUME BALANCE IN HEMODIALYSIS A. Factors decreasing intravascular volume 1. Ultrafiltration 2. Solute removal decreased osmolality of post dialyzer blood water moves out into intracellular compartment decreased plasma volume B. Factors replenishing intravascular volume 1. Plasma refilling rate (UF increased albumin conc. in intravascular compartment increased colloid oncotic pressure water moves in from the intracellular compartment)
2. Increased cathecolamines a. Increased vascular resistance b. Increased HR and contractility
VOLUME BALANCE IN HEMODIALYSIS II. Venous capacity A. Acetate induced venodilatation B. Dialysate temperature C. Food ingestion D. Dialysate sodium DIALYSIS-RELATED IMPAIRMENT TO COMPENSATORY RESPONSES IV. Vascular resistance A. Anemia B. Acetate C. Temperature D. Food ingestion E. Sodium F. Potassium G. Calcium H. Dialyzer membrane I. Drugs DIALYSIS-RELATED IMPAIRMENT TO COMPENSATORY RESPONSES Strategy to help prevent hypotension during dialysis 1. Use a dialysis machine with an ultrafiltration controller whenever possible. 2. Counsel patient to limit salt intake, which will result in a lower interdialytic weight gain, ideally <1 kg / d. 3. Do not ultrafilter to below patients dry weight. 4. Keep dialysis solution sodium level at or above the plasma level or use sodium gradient dialysis (controversial). 5. Give daily dose of antihypertensive medications after, not before, dialysis. COMMENTARY: Dialysate Sodium 1. Low Dialysate Na increased generation of PGE 2 2. Warning: Never use a dialysate Na lower than the patients Na. Risk of cerebral edema 3. Sodium profiling: linear, exponential, ramped 4. Recommendations: a) High Na (144 150) b) Sodium profiling 6. Use bicarbonate containing dialysis solution 7. In selected patients, try lowering the dialysis solution temperature to 34 36C. 8. Ensure the hematocrit is > 33% prior to dialysis. 9. Do not give food or glucose orally during dialysis to hypotension prone patients. 10. Consider use of blood volume monitor. 11. Consider use of -adrenergic agonists (midodrine) prior to dialysis.
Strategy to help prevent hypotension during dialysis 1. Obligatory increase in splanchnic blood flow 2. Lasts for 2 hours 3. No food intake during dialysis is recommended only to those prone to IDH COMMENTARY: .Food Ingestion MANAGEMENT OF DIALYSIS HYPOTENSION A. Improve cardiac filling 1. Expand intravascular volume [ 0.9 NSS /colloid bolus] 2. Increase plasma refilling [ hypertonic saline / glucose ] B. Supportive 1. Decrease UFR 2. Trendelenburg position 3. Oxygen 4. Decrease BFR *( ? ) TROUBLE SHOOTING DIALYSIS COMPLICATIONS PROBLEM MECHANISM PREVENTION TREATMENT 1. Cramps
2.Dysequilibrium syndrome
a. hypotension 1. correct hypotension a. 0.9 NSS b. px below dry 2. correct dry weight b. hypertonic glucose weight c. hypertonic saline c. low sodium 3. sodium profilling* dialysate 4. higher sodium 5. vitamin E 400 iu hs 6. Carnitine 7. Quinine 8. Oxazepam
a. cerebral edema 1. slow initial BFR a. supportive b. cellular acidosis 2. limit initial UFR b. hypertonic glucose 3. mannitol c. hypertonic saline 4. sodium profiling
TROUBLE SHOOTING DIALYSIS COMPLICATIONS PROBLEM MECHANISM PREVENTION TREATMENT
3. Dialysis associated hypoxemia
4. Conductivity
a. metabolic alkalosis 1. identify pxs at risk a. terminate HD b. complement 2. higher O2 b. ventilate px activation 3. hydrocortisone*
a. high 1. check system a. correct it - low water
b. low 1. check system a. correct it - empty dialysate - defective proportioning pump
c. wrong dialysate 1. pre HD check a. get a good combination lawyer TROUBLE SHOOTING DIALYSIS COMPLICATIONS PROBLEM MECHANISM PREVENTION TREATMENT 5. Arterial pressure
a. High 1. Insertion technique a. repositioning/ - needle/catheter 2. periodic AVF Doppler reinsertion positioning assessment b. tourniquet - AVF flow (arterial) - hypotension
b. Low 1. pre HD check a. eliminate air and - disconnected 2. WOF air embolism reconnect lines
TROUBLE SHOOTING DIALYSIS COMPLICATIONS PROBLEM MECHANISM PREVENTION TREATMENT
6. Venous pressure
a. High 1. periodic AVF Doppler a. NSS flushing - AVF pressure assessment b. readjust BFR - high BFR 2. reassess anticoag. (too fast vs. too slow) - clotting in system protocols - kinked tubings 3. target best BFR
b. Low 1. WOF air embolism a. eliminate air and - disconnected lines reconnect
Peritoneal dialysis
Continuous ambulatory peritoneal dialysis (CAPD)
2 liters dialysate, replaced every 4-6 hours
Continuous cyclic peritoneal dialysis (CCPD Peritoneal dialysis In evaluating a client's understanding of administration of peritoneal dialysis which client action would require an intervention by the nurse? The client warms the dialysate before starting the infusion. The client uses soap and water to clean ports before connecting to dialysis tubing. The client weighs himself before starting process The client wears sterile gloves when connecting/disconnecting the tubing
Peritoneal dialysis A client with chronic renal failure is undergoing peritoneal dialysis. Which nursing measure will be most helpful in promoting outflow drainage of the dialyzing solution? Turn the client from side to side. Elevate the height of the dialysate bag. Apply manual pressure to the clients lower abdomen. Push the peritoneal catheter in approximately one inch further.