DIALYSIS

CRESENCIO C. CAJIGAL, JR. RN, MAN

Kidney

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. 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 Complications

EQUIPMENTS
 

     

Dialysis Machine Dialysis Tubing arterial line-red Tubing linevenous line-blue lineIVF/IV line Dialyzer 2 needles 2 10cc syringe Heparin 6cc Dialysate solution acetate, bicarbonate

Steps in Hemodialysis Process

 Priming  Recirculation

-15 minutes.  Dialysis process 4 hours  Termination

MOST COMMON HEMODIALYSIS COMPLICATIONS

1. 2. 3. 4. 5. 6. 7.

Hypotension Cramps Nausea / Vomiting Headache Chest pain Back pain Chills

20 - 30% 5 - 20% 5 - 15% 5% 2 - 5% 2 - 5% 1%

INTRADIALYTIC HYPOTENSION [IDH]

Definition: * Sudden drop in systolic BP to < 90 mmHg * > 30 mmHg drop in MAP * > 30 mmHg drop in systolic BP + symptoms

SYMPTOMS OF HYPOTENSION
1. 2. 3. 4.

Nausea / Vomiting Cramps Light headedness / dizziness For some, none

INTRADIALYTIC HYPOTENSION A. Early

1. 2. 3. 4. Dialyzer volume Medications Sepsis Pericardial disease

B.

Late

1. High UFR a. high interdialytic weight gain b. too low dry weight 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) b) c)

systolic dysfxn diastolic dysfxn 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

VOLUME BALANCE IN HEMODIALYSIS

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

DIALYSISDIALYSIS-RELATED IMPAIRMENT TO COMPENSATORY RESPONSES

II.

Venous capacity A. Acetate induced venodilatation B. Dialysate temperature C. Food ingestion D. Dialysate sodium

DIALYSISDIALYSIS-RELATED IMPAIRMENT TO COMPENSATORY RESPONSES

IV. A. B. C. D. E. F. G. H. I.

Vascular resistance Anemia Acetate Temperature Food ingestion Sodium Potassium Calcium Dialyzer membrane Drugs

Strategy to help prevent hypotension during dialysis

1.

2.

3. 4.

5.

Use a dialysis machine with an ultrafiltration controller whenever possible. Counsel patient to limit salt intake, which will result in a lower interdialytic weight gain, ideally <1 kg / d. Do not ultrafilter to below patients dry weight. Keep dialysis solution sodium level at or above the plasma level or use sodium gradient dialysis (controversial). Give daily dose of antihypertensive medications after, not before, dialysis.

COMMENTARY: Dialysate Sodium

1. 2.

3. 4.

Low Dialysate Na increased generation of PGE 2 Warning: Never use a dialysate Na lower than the patients Na. Risk of cerebral edema Sodium profiling: linear, exponential, ramped Recommendations: a) High Na (144 150) b) Sodium profiling

Strategy to help prevent hypotension during dialysis

6. 7.

8.

9.

10. 11.

Use bicarbonate containing dialysis solution In selected patients, try lowering the dialysis solution temperature to 34 36C. 36 Ensure the hematocrit is > 33% prior to dialysis. Do not give food or glucose orally during dialysis to hypotension prone patients. Consider use of blood volume monitor. Consider use of E-adrenergic agonists (midodrine) prior to dialysis.

COMMENTARY: .Food Ingestion

1.

2. 3.

Obligatory increase in splanchnic blood flow Lasts for 2 hours No food intake during dialysis is recommended only to those prone to IDH

MANAGEMENT OF DIALYSIS HYPOTENSION

A.

B.

Improve cardiac filling 1. Expand intravascular volume [ 0.9 NSS /colloid bolus] 2. Increase plasma refilling [ hypertonic saline / glucose ] Supportive 1. Decrease UFR 2. Trendelenburg position 3. Oxygen 4. Decrease BFR *( ? )

TROUBLE SHOOTING DIALYSIS COMPLICATIONS

PROBLEM 1. Cramps MECHANISM a. hypotension b. px below dry weight c. low sodium dialysate PREVENTION 1. correct hypotension 2. correct dry weight 3. 4. 5. 6. 7. 8. 1. 2. 3. 4. sodium profilling* higher sodium vitamin E 400 iu hs Carnitine Quinine Oxazepam slow initial BFR limit initial UFR mannitol sodium profiling a. supportive b. hypertonic glucose c. hypertonic saline TREATMENT a. 0.9 NSS b. hypertonic glucose c. hypertonic saline

2.Dysequilibrium syndrome

a. cerebral edema b. cellular acidosis

TROUBLE SHOOTING DIALYSIS COMPLICATIONS

PROBLEM 3. Dialysis associated hypoxemia MECHANISM a. metabolic alkalosis b. complement activation PREVENTION 1. identify pxs at risk 2. higher O2 3. hydrocortisone* TREATMENT a. terminate HD b. ventilate px

4. Conductivity

a. high - low water

1. check system

a. correct it

b. low 1. check system - empty dialysate - defective proportioning pump c. wrong dialysate combination 1. pre HD check

a. correct it

a. get a good lawyer

TROUBLE SHOOTING DIALYSIS COMPLICATIONS

PROBLEM 5. Arterial pressure

MECHANISM a. High - needle/catheter positioning - qAVF flow (arterial) - hypotension b. Low - disconnected lines

PREVENTION 1. Insertion technique 2. periodic AVF Doppler assessment

TREATMENT a. repositioning/ reinsertion b. tourniquet

1. pre HD check 2. WOF air embolism

a. eliminate air and reconnect

TROUBLE SHOOTING DIALYSIS COMPLICATIONS

PROBLEM 6. Venous pressure

MECHANISM a. High - oAVF pressure - high BFR - clotting in system - kinked tubings b. Low - disconnected lines

PREVENTION 1. periodic AVF Doppler assessment 2. reassess anticoag. protocols 3. target best BFR 1. WOF air embolism

TREATMENT a. NSS flushing b. readjust BFR (too fast vs. too slow)

a. eliminate air and reconnect

Peritoneal dialysis
Continuous ambulatory peritoneal dialysis (CAPD) 2 liters dialysate, replaced every 4-6 dialysate, 4hours 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.

THANK YOU!!!!