Serial No - NHS Wales
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Serial No.:
Ref. No.: BLUP1/MED/00
POLICY
Home Haemodialysis
Draft No: …1... Date: 17/02/2009
|Number Of Pages | |
|Ratification Information |
|Ratifying Body |Medicine Directorate Management Team |Ratified By |Chairperson |Date Ratified |TBA |
| | |(Named Person) | | | |
|In accordance with the Validation & Ratification Schedule which was approved by Trust Board |
|Document Responsibilities | |Document History |
|Originator / Author (Person |Senior Sister Julie Oliver and the Home | |First Operational |11/12/03 |
|Responsible For Review) |Therapies Team | | | |
| |Jackie Williams | | | |
| | | |Previously Reviewed (Updated At Review |N/A | |
| | | |- Yes/No) | | |
| | | | |N/A | |
|Owning Department |Renal Department, Medicine Directorate. | | |N/A | |
| | | | |N/A | |
|Validated By |Dr Drew | |Next Review Date |TBA |
|Date Validated |TBA | |Operational Date |TBA |
|Summary Of Current Review Changes |
|N/A |
|Contains References to the following Documents |
|Document Title & Reference |Universal blood and body fluid precautions. |
|Document Title & Reference |Permission granted by Fresenius to use all their policies within the operators’ manual. Their policies have |
| |been adapted for the use of the renal therapies team. |
|Document Title & Reference | |
|Document Title & Reference | |
|Document Title & Reference | |
Table Of Contents
1. Mission Statement 5
1.2 Purpose 5
1.3 Scope 5
2. Orientation / Patient Information 5
2.1 Medications 5
2.2 Labs 6
3. Clinical Records/Documentation 6
3.1 Treatment Records 6
3.2 Hospitalizations 6
3.3 Clinic/Home Visits 6
4. Training 7
4.1 Staff Training 7
4.2 Patient Training 7
4.4 Access Management & Evaluation 7
5. Infection Control 8
6. Equipment 8
6.1 Dialysis Machine and RO Unit - AQUA UNO 8
6.1.2 Machine Settings 8
6.1.3 Routine Procedures 8
6.1.4 Alarms & Troubleshooting 8
6.1.5 Maintenance 9
6.1.6 Water Treatment. 9
7. Equipment Preparation 9
7.1 Pre- Treatment Preparation 9
7.2 Treatment 9
7.3 Post- Treatment 9
8. Complications during Home Dialysis 10
9. Contacts 10
10. Procedures 10
AIR EMBOLISM 11
AIR TRAP LEVEL MONITORING 12
BLOOD LOSS 13
DIALYZER BLOOD LEAK 14
DIALYSIS INTERRUPT AND RECIRCULATION 15
GIVING SALINE FLUSH MANNUALLY – If patient on HD or online bolus not available 16
DISASTER - FIRE 17
DRAWING POST U & E 18
FEVER AND/OR CHILLS 19
HAEMOLYSIS 20
HYPOTENSION 21
MANUAL SALINE RINSEBACK 22
MONITOR THE DIALYSIS TREATMENT 24
MUSCLE CRAMPS 25
NEEDLE INFILTRATION 26
PROCEDURE FOR THE INSERTION OF SHARP NEEDLES FOR DIALYSIS 27
CANNULATION OF AV FISTULA USING BUTTONHOLE TECHNIQUE STANDARD AV FISTULA NEEDLES 29
POWER LOSS 32
PREPARE FOR DIALYSIS 34
RINSEBACK POST-DIALYSIS 37
ARTERIAL PRESSURE DEVICE DOES NOT OPEN WHEN LINE GUIDE IS INSERTED 38
HAEMOCONCENTRATION WARNING 39
COLLECT WATER SAMPLE SAMPLE FOR RESIDUAL CHEMICAL ANALYSIS 40
COLLECT WATER SAMPLE FOR CHLORINE TESTING 41
COLLECT ONLINE SAMPLE FOR QA WATERS AND RO SAMPLE FOR QA AND CHANGE DIASAFE PLUS FILTERS 42
1. Mission Statement
The home therapies team is committed in providing a service that is safe and appropriate to our patients needs. We will continue to review and improve our services and will benchmark with other agencies so that this can benefit our patients or the wider community.
1 Purpose
To train a patient, safely, efficiently and competently in readiness to carry out home haemodialysis.
3 Scope
Every trained nurse within the home therapies team.
2. Orientation / Patient Information
Introduces the patient to the home therapies team. Potential new client’s checklist will be completed covering aspects such as vascular access, how Haemodialysis works and the benefits of dialysis, the training involved as listed in section 4.2, storage of equipment required for home dialysis, holidays, and educational tools to facilitate patient training. The patient will be informed of any necessary alterations that may be needed within the home and the Fresenius technician will carry out a preliminary home visit in the home to assess suitability of the Fresenius system. The technician will inform the patient of any alterations required and will also inform the Estates Department and Home Therapies team of all alterations necessary. Following identification of a suitable patient the patient will be informed of the time scale necessary prior to commencing home Haemodialysis.
The patient will be informed of training objectives to be met prior to commencing dialysis at home, and will be required to sign his/her objectives to say they are happy to carry out their home therapy treatment.
2.1 Medications
The home therapy team will discuss the medications used, explaining any potential side effects. This aspect is covered in the document:-
Home Haemodialysis client training objectives within the nursing care plan.
The patient will be informed that drug dosages may be changed after a period of time on home Haemodialysis due to the frequency of dialysis. It will be explained to the patient that any alterations needed will be via GP via fax and phone calls.
The patient will also be informed that if the acid concentrate is changed the old dialysate will need to be disposed of immediately.
3 Labs
Frequency of required blood, and water testing will be explained to the patient. Request forms, details of blood tests and water testing will be included within the patient’s care plan and will be discussed during the training.
3. Clinical Records/Documentation
Within the Nursing care plan documentation will be included:- Patient diagnoses, patient care plans and physician orders (meds, labs, and treatment settings). Dialysis Prescriptions Policies/Procedures include staff instructions/forms on recording, updating and maintaining these records. Home Haemodialysis Patient Training Schedule and Objectives forms.
3.1 Treatment Records
Within the patients care plan documentation will be included: - Patient treatment Fresenius system prescription settings, maintenance information, due dates of bloods and water testing, blood forms and bottles required for specific tests. Water samples, and details required for specific tests, home dialysis policies, and useful contacts and telephone numbers.
3.2 Hospitalizations
Documents dates, admitting diagnosis within the nursing care evaluation and progress report.
The patient is also informed of any problems with their machine, to inform the home Haemodialysis team as the patient may require Haemodialysis on the renal unit whilst the machine is being repaired. This is discussed within the home Haemodialysis client training objectives.
5 Clinic/Home Visits
Clinic appointments and where the clinics are held, what to bring along to clinic and who will be available to be seen are explained within the client training objectives document.
Home visits and support is also explained within the client training objectives document.
4. Training
4.1 Staff Training
Staff training is carried out over a three week period by a clinic nurse specialist from Fresenius.
The staff are required to achieve the 5008 System Training Schedule and complete these objectives prior to training their clients.
4.2 Patient Training
Documents patient home training program/skills assessment and continuing education/training and evaluation
a) Use of the Home Haemodialysis Patient Training Schedule and Objectives
b) Home Haemodialysis information booklet
c) Use of the 5008 Therapy System – Training and Resource Guide
d Use of the 5008 Therapy System Brief Operating Guide
Once the patient is competent to carry out home haemodialysis, home modifications are complete, the Home Haemodialysis machine has been commissioned and passed microbiology and chemical analysis, the trained nurse will follow the patient home and spend the first few days ( 1 week ) with the patient to ensure that everything is in place and can competently carry out his or her dialysis, facilitating the transition from Hospital to Home.
4.3 Anemia Management & Evaluation
The patient’s Haemoglobin and ferritin will be monitored every month and documented within the nursing care plan on the blood results document.
Any changes in erythropoeitin doses are faxed to either GP or the appropriate home delivery company.
I.V. iron clinics are carried out within the renal unit on an outpatient basis.
The patient’s results are continually audited via our anaemia audit tool.
4.4 Access Management & Evaluation
The access co-ordinator educates the patient to self-needle and care for his/her access. Where indicated Central Venous Catheter training will be carried out (if vascular access has failed or for those patients where Central Venous Catheter is their access). She explains correct needling technique, the importance of correct procedure and demonstrates the correct procedure. She identifies signs of infection of vascular access and the treatment of infection. This is taught in the home haemodialysis client training objectives.
5. Infection Control
During patient training the importance of infection control will be highlighted, and the patient will be required to meet client training objectives. The area where home haemodialysis is to be carried out will be free from infection, the patient will also be advised on how to keep the area clean and tidy. The patient will be taught hand washing and hand hygiene and the importance of using the technique. Universal precautions will be discussed and the patient will need to meet the training objectives. Included, will be the importance of disposing needles and sharps, the patient will be taught the safe disposal of needles and sharps into the provided sharps bins. Clinical waste will be explained and the importance of disposing all clinical wastes into the correct bags, the patient will be informed of the procedure for clinical waste collection as per local and national guidelines. As the home haemodialysis machine is used for one patient only, the cleaning of the machine is to be as per recommendations from Fresenius.
6. Equipment
6.1 Dialysis Machine and RO Unit - AQUA UNO
The home haemodialysis team during training will define the technical requirements for the dialysis machine and the use of RO unit.
a) Technical requirements
b) The patient will be briefly taught how the haemodialysis machine and the Aqua Uno RO works
6.1.2 Machine Settings
During the patient training the patient will be taught how to enter/change treatment, prescription and machine settings on the dialysis machine as per Fresenius training checklist.
6.1.3 Routine Procedures
Describes how to perform general and / or more frequent procedure
6.1.4 Alarms & Troubleshooting
Describes how to respond to- information message (Info), Warning message (Warning) and Alarm message (Alarm) alarms and to perform troubleshooting procedures. Use of 5008 Haemodialysis System Operating Instructions.
a) Problem solving – issues that may arise
b) Brief guide and troubleshooting for the Fresenius 5008
6.1.5 Maintenance
Every 12 months the technician carries out Function Check and Electrical Safety maintenance on the home haemodialysis machine, and every 2 years Major service is carried out.
a) Fresenius maintenance programme.
6.1.6 Water Treatment.
Describes the water treatment system (water pre-treatment and RO) and importance of water treatment. Instructs staff/patient on monitoring, maintenance and documentation. Policies/procedures may include instructions/forms re monitoring.
Procedures:
a) Monthly QA waters from machine and RO as per policy
b) Monthly change of Diasafe Plus Filters
c) 6 monthly waters for Trace Elements from RO
d) Disinfection of RO and machine as per policy
7. Equipment Preparation
7.1 Pre- Treatment Preparation
Describes procedures performed during dialysis preparation in conjunction with Patient Prescription.
Procedures: –
a) T1 Test and Preparing and lining the dialysis machine
b) Preparation of the treatment area and consumables for needling
c) Patient preparation
d) Completion of pre treatment checklist and dialysis data record sheet
2 Treatment
Describes procedures performed during treatment.
Procedures:
a) Monitoring the prescribed Dialysis treatment
b) Discontinuation of the prescribed dialysis treatment
7.3 Post- Treatment
Describes procedures performed during treatment.
Filling in the dialysis data sheet and records any problems encountered.
Reports any problems to the Home Therapies Nurse / Technician.
8. Complications during Home Dialysis
Describes how to treat patient complications and natural events that occur during dialysis.
Procedures:
Air embolism – Page 10
Disaster- fire – Page 20
Haemolysis – Page 23
Muscle cramps – Page 28
Power loss – Page 31
Dialyzer blood leak – Page
Blood loss – Page
Fever and/or chills – Page
Hypotension – Page
Needle infiltration (needle blow ) – Page
Haemoconcentration – Page
Arterial Pressure Device - Page
Contacts
Renal unit home therapies telephone numbers 01978 727101 / 727103 between 9am-5pm.
24 hr on call service out of hours ring 01978 291100 and ask switch board to put you through to the on call home therapies team / CAPD nurse on call.
The patient is issued with our contact numbers and the Fresenius technicians telephone numbers on commencement of training.
Procedures
9.
|Procedure |AIR EMBOLISM |
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|Description | |
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|Purpose | |
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| |This procedure describes how to treat an infusion of air into the patient’s bloodstream |
| | |
| |Loose or cracked arterial connections, separation of arterial blood tubing from arterial needle or catheter can introduce |
| |air into the blood tubing and dialyzer. Operator error when troubleshooting venous air in blood alarms or machine |
| |malfunction may inadvertently allow air to enter the patient. Not correcting Air / Blood levels in venous bubble trap, |
| |venous blood line not inserted correctly in Blood air optical detector. |
| | |
| |The dialysis machine safety monitors, and secure and tight connections along the access, dialyzer and blood tubing can |
| |prevent an air embolism. |
|Procedure |Rationale |
|Call 999 |Stops blood pump and closes arterial and venous clamps. |
|Stop the Blood pump. | |
|Clamp the patient’s access and blood tubing lines. |Traps air in right atrium and minimizes risks to the patient. |
|Place the patient on left side with head down and feet up higher than| |
|head. | |
|Monitor patient’s vital signs i.e. Blood pressure and pulse. Do not | |
|panic. | |
| | |
|Call home training nurse. | |
|Procedure |AIR TRAP LEVEL MONITORING |
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|Description | |
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|Purpose | |
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|Reference | |
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| |This procedure describes how to monitor for any loose connection in the blood tubing set via the blood/air optical detector |
| |seated below the venous bubble trap. |
| | |
| |Loose connections between the blood tubing, injection site and access lines can cause air to leak into the blood tubing and |
| |result in frequent air trap leveling and blood tubing set error alarms. |
| | |
| |Fresenius 5008 Operators Manual –Alarm Processing 2 parts |
| |(1)Air detected below the Venous Bubble Catcher |
| |(2)Micro Bubbles detected below the Venous Bubble Catcher |
|Supplies |None |
|Procedure |Rationale |
| | |
| | |
|If the blood level is lower than 1cm from top of bubble trap PRESS Blood |Discontinuing a treatment earlier than prescribed may require the |
|System key and use the arrows to raise the level or PRESS Level Set Key – |patient’s schedule to be adjusted. |
|machine will set automatically. | |
|Check that all the connections are secure. | |
|If required the machine will request the user to follow informational | |
|messages on the screen to remove the air. |During the air removal procedure the blood pump will run at a rate of|
|If necessary disconnect from dialysis, connect the arterial and venous blood |50ml/min |
|lines to a bag of normal saline, until air is removed form lines following | |
|instructions on the dialysis machine. |N.B. The blood pump speed will require increasing back to prescribed |
|If, after careful observation, the above conditions continue, discontinue |speed |
|treatment and call Fresenius Technical Service Center and the renal unit. | |
|If in HD Mode prime with 1.0L to reduce the risk of air bubbles. | |
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|Procedure |BLOOD LOSS |
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|Description | |
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|Purpose | |
|Reference | |
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| |This procedure describes what to do in the event of a needle slippage, or tubing disconnection. |
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| |Recirculation |
| |Reinsertion of a new needle |
|Supplies |None |
|Procedure |Rationale |
|Stop the Blood Pump by pressing the red LED key on left of monitor. If the | |
|needle is dislodged immediately apply pressure on the site. | |
| | |
|Clamp access lines and blood tubing. | |
| | |
|Assess blood loss and check vital signs i.e. blood pressure and pulse. | |
| | |
|Follow procedure for recirculation | |
|Circulation key right hand side of monitor | |
|Commence recirculation - using recirculation band | |
| | |
|Insert a new needle by following the reinsertion of a new needle procedure. |Blood will be pulled from the intact access/blood tubing assembly as |
| |air is pushed out of the disconnected tubing. |
|Following reinsertion of new needle reconnect blood lines to access to resume| |
|dialysis. | |
| | |
|Remembering to clean the patient connector on the blood tubing with an | |
|alcohol wipe prior to reconnection (to reduce the risk of infection). |N.B. The blood pump speed will require increasing back to prescribed |
| |speed |
|NOTE: Patient’s blood in the tubing may be at risk for clotting therefore if | |
|this occurs discontinue dialysis NOTING therapy time remaining and UF | |
|remaining. | |
| | |
|Notify the home training unit. | |
|Procedure |DIALYZER BLOOD LEAK |
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|Description | |
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|Purpose | |
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|Reference | |
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| |This procedure describes what to do in case of dialyzer rupture. |
| | |
| | |
| |Leaks or tears in the dialyzer membrane can cause red blood cells to cross over into the dialysate. When this occurs |
| |treatment must end. |
| | |
| |Fresenius 5008 Operator’s Manual |
|Supplies | |
|Procedure |Rationale |
|When the machine detects blood in the dialysate a blood leak warning alarm is| |
|displayed on the touch screen. | |
|Check the dialyser for signs of blood in the dialysate fluid |2 |
|Check Dialysate line ( blue) draining away from the dialyser | |
| | |
|If you can identify blood (rusty or pink ) in dialysate fluid STOP blood | |
|pump, clamp machine lines and patient lines. DO NOT WASH BACK. | |
| | |
|Disconnect. Flush needles. | |
|Discard blood circuit and dialyser |The redundant filtering system protects against contamination of the |
|Contact nurse on call Home Therapies. |ultrapure dialysate that is infused into the patient. |
| | |
|If there is no evidence reset alarm. If blood leak alarm continues x3 presume| |
|you have a microscopic blood leak and wash back. | |
| | |
|Discard blood lines and dialyser. | |
| | |
|Note the time left and amount of UF left to be removed | |
|Put machine through heat disinfectant BEFORE restarting next dialysis session| |
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|Procedure |DIALYSIS INTERRUPT AND RECIRCULATION |
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|Description | |
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|Purpose | |
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|Reference | |
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| |This procedure describes how to temporarily disconnect a patient from the 5008 Fresenius machine during treatment, |
| |recirculate blood in the Extracorporeal circuit (EC), reconnect a patient and continue with dialysis. |
| | |
| |Dialysis can be temporarily interrupted when the patient needs to disconnect from the extracorporeal circuit. Dialysis will|
| |continue after the patient is reconnected to the extracorporeal circuit. |
| | |
| |Fresenius 5008 Operator’s Manual |
|Supplies |1 – Recirculation connector |
| |2 – 2 x 10 ml syringes with saline for flushing needles |
|Procedure |Rationale |
|Use alcohol rub and universal precautions when performing this procedure. | |
|Ensure all connections are secure when connecting and disconnecting the blood| |
|tubing set. | |
| | |
|Disconnect and Prepare for Recirculation. | |
|Gather supplies. | |
|Press the options menu and select circulation. Press recirculate.This will | |
|automatically stop pump and switch off UF. | |
|Clamp the arterial blood line and arterial needle. |Pauses the machine |
|Clamp the venous blood line and the venous needle. | |
|Disconnect both lines from both needles and connect to the recirculation | |
|connector. | |
|Attach a 10ml syringe of saline to the arterial and venous needles, flush | |
|needles as necessary. | |
|Release the clamps on arterial and venous blood lines and press recirculate | |
|on screen. | |
|Ensure a primed bag of normal saline is connected to the circuit. | |
|Warnings every 5 mins alert the user to the fact that the circuit is | |
|recirculating. | |
| | |
| | |
|.To go back on dialysis…… | |
|Press “stop recirculation” | |
|Clamp the saline. | |
|Clamp the arterial and venous blood lines | |
|Disconnect the arterial blood line from the connector and attach to the | |
|arterial needle. | |
|Transfer the 10ml syringe to the connector. | |
|Disconnect the venous line from the | |
|Connector and attach it to the venous needle. | |
|Release the clamps on both needles and both blood lines. | |
| | |
|CHECK FOR AIR IN BLOOD TUBING AND NEEDLES |N.B. Increase pump speed back to Prescribed pump speed. |
|When you are happy recommence the blood pump and recommence UF. | |
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| | |
|Procedure |GIVING SALINE FLUSH MANNUALLY – If patient on HD or online bolus not available |
| | |
|Description | |
| | |
| | |
|Reference | |
| |Saline flush may be needed during dialysis if patient records a low blood pressure or experiences symptoms of a low blood |
| |pressure i.e. Clammy, warm or sweaty. Dizzy, light headed, nauseous, visual disturbances or hearing disturbances. |
|Procedure |Rationale |
|Saline restores your blood pressure by increasing the volume in your | |
|circulation. | |
|To give saline…. | |
|1- Reduce the speed of the blood pump by 5mmhg to open the top arterial |To prevent arterial alarms while infusing the saline. |
|pressure guard, and the lower venous pressure guard. | |
|2- Turn UF off | |
|3- Ensure saline is attached to the circuit, line is primed , then release | |
|clamp on the saline port. | |
|Giving saline alters the venous and arterial pressure. | |
|4- Give as much saline as you need (check blood pressure) | |
|5- Increase the blood pump speed to the original setting |This opens the lower arterial guard and the top venous pressure |
|6- Clamp the saline port. The venous and arterial pressures will return to |guard. |
|the original level. | |
|7- Recheck your blood pressure. | |
|8. If patient still unwell post infusion dial 999 | |
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|Procedure |DISASTER - FIRE |
| | |
|Description | |
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|Purpose | |
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|Reference | |
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| |This procedure describes how to safely disconnect from the machine in the event of an earthquake, fire or severe weather. |
| | |
| |To assure that the patient can safely move away from the machine to find shelter. |
| | |
| |None |
|Procedure |Rationale |
|Stop blood pump. |Stops all pumps and closes all clamps |
|Turn off the power supply to the machine | |
|Clamp the arterial and venous access lines | |
|Clamp the arterial and venous blood tubing | |
|Disconnect or cut the arterial blood tubing | |
|Disconnect or cut the venous tubing | |
|Keep the patient close to the floor and move to a safe area and leave | |
|building. | |
|Secure the patient’s access and check for injuries. Call for help. | |
|Contact renal unit for arrangement of dialysis on the unit. | |
|Procedure |DRAWING POST U & E |
| | |
|Description | |
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|Purpose | |
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|Reference | |
|Supplies | |
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| |This procedure describes how to take blood samples for monitoring delivered dose of dialysis. |
| | |
| |For the purpose of monthly blood results. |
| | |
| | |
| |Appropriate blood bottles and 10 ml syringe. |
|Procedure |Rationale |
|Prior to Washback - prepare supplies needed to collect sample. | |
|When time remaining equals 0 | |
|Lower the pump speed to 50mL/min. | |
|Wait 15 seconds. | |
|Press the Red Stop pump LED key. | |
|Clamp the venous needle clamp and clamp the venous blood tubing clamp. |Lowering the blood flow rate prevents the potential for |
|Disconnect the venous blood tubing from the venous needle. |collecting recirculated blood. |
|Place a 10ml syringe at the end of the venous needle, then unclamp venous needle and |Allows systemic blood to reach |
|withdraw post blood sample. |sample port. |
|Clamp venous needle clamp, then remove syringe and place blood sample in appropriate | |
|blood bottle. | |
|Reconnect venous needle to venous blood tubing making sure that connection is secure. | |
|Unclamp venous blood tubing clamp and venous needle clamp. | |
|Machine will show “Reinfusion” and follow on screen instructions, and washback as | |
|normal. | |
|Following treatment please bring sample to the unit within an hour of taking the blood | |
|sample. | |
| | |
| |To minimize inaccurate blood results. |
|Procedure |FEVER AND/OR CHILLS |
| | |
|Description | |
| | |
| | |
|Reference | |
| | |
| |This procedure describes what to do when a patient complains of fever and / or chills. |
| | |
| |Fresenius 5008 Operator’s Manual |
|Procedure |Rationale |
|Check patient’s vital signs i.e. blood pressure and pulse. | |
|Note the temperature of the dialysate on the screen. | |
|Cover patient with blanket. | |
|Determine when symptoms started. | |
| |An elevated temperature before dialysis and between dialysis may |
| |indicate infection. |
| |A normal temperature with shivering may indicate dialysate that is |
| |too cold for the patient. |
| |An elevated temperature within the first 30 to 60 minutes of starting|
| |dialysis may indicate a pyrogen reaction. |
|Discontinue treatment if a pyrogen reaction is suspected. Notify the home | |
|training unit for further instructions. | |
|Procedure |HAEMOLYSIS |
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|Description | |
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|Purpose | |
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|Reference | |
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| |This procedure describes what to do in the event of Haemolysis. |
| | |
| |High negative pressures, kinked or defective tubing, improperly mixed, or overheated dialysate and contaminants from water |
| |used to make dialysate can cause haemolysis. |
| |The machines safety monitors and proper checks, observations and monitoring by the operator can prevent haemolysis from |
| |occurring. |
| | |
| |Fresenius 5008 Operator’s Manual |
|Procedure |Rationale |
|Stop the blood pump. |Stops blood pump and closes arterial venous clamps. |
| | |
|Clamp arterial and venous access lines. |Ruptured red blood cells release potassium that can cause abnormal |
| |heart rhythms. |
|Disconnect patient from the machine . DO NOT return blood to the patient. | |
| |Patient may experience shortness of breath, hypotension and abnormal |
|Monitor vital signs i.e. blood pressure, pulse, breathing rate. |heart rhythms. |
| | |
|If necessary, give saline to replace volume of blood lost – via saline IVI. | |
| | |
|Call home training nurse for instructions on care of the patient. | |
|Call Technical Assistance Center for assistance in troubleshooting the cause | |
|of haemolysis. |Patient may experience cardiac arrest. |
|If symptoms are severe, call 999 | |
|Procedure |HYPOTENSION |
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|Description | |
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|Purpose | |
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|Reference | |
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| |This procedure describes what to do when the patient’s blood pressure drops during treatment. |
| | |
| |Low blood pressure can be caused by rapid removal of fluid or other medical conditions. |
| |Low blood pressure during treatment can cause dizziness, vomiting, visual disturbances, loss of consciousness or seizures. |
| | |
|Procedure |Rationale |
|NB. If on haemodialysis and not HDF follow instructions for Giving Saline. | |
|Press Emergency button + |Switches off UF, reduces pump speed, takes blood pressure and gives |
|Attach Blood pressure cuff |bolus of online fluid 150 ml intervals. |
| | |
|Lower the patient’s head and raise their feet. | |
|Assess patient vitals signs i.e. blood pressure, pulse. | |
|Note signs and symptoms that led to hypotensive episode. |Assessment will determine intervention |
|. | |
|When solution infusion is complete and blood pressure is stabilized continue | |
|with dialysis. |Querry reduce UF volume |
|ENSURE UF IS SWITCHED ON AND BLOOD PUMP IS AT PRESCRIBED SPEED. | |
| | |
|If necessary, decrease target fluid to remove, or extend patient’s treatment.| |
|Document observations. Document total solution infusion given and any |Lowers the ultrafiltration rate |
|treatment setting changes. |Solution infusion and changes to fluid to be removed is included in |
| |the post weight assessment. |
|If patient’s blood pressure does not stabilize, notify home training unit – |Low blood pressure may be due to other medical conditions. |
|-Weight assessment may be required | |
|-Blood pressure medication may need | |
|adjusting | |
| | |
| | |
| | |
| | |
| | |
| | |
|Procedure |MANUAL SALINE RINSEBACK |
|Description | |
| | |
| | |
|Purpose | |
| | |
| | |
| | |
| | |
|Reference | |
|Supplies | |
| |This procedure describes how to manually return the patient’s blood during alarm conditions that prevent an automated rinse |
| |back. |
| | |
| |Alarms that require a manual saline rinse back include: |
| |Unrecoverable alarms |
| |Recoverable alarms that do not allow rinse back and online infusion not available |
| | |
| |Power failure |
| |Fresenius 5008 Operators Manual |
| |1 – 1,000 mL bag of sterile saline |
| |1 – IV administration set with recirculation band connected |
| |1 – IV pole on Machine |
|Procedure |Rationale |
|Note: Use the alcohol rub and universal precautions when performing this procedure | |
|as taught during training. | |
|Ensure all connections are secure when connecting and disconnecting the blood tubing| |
|set. | |
| | |
|Set up and Connection | |
|Hang the saline bag on the IV pole and attach the IV administration set with | |
|attached recirculation connector to the bag. (Make sure connections are secure). | |
|Close roller clamp and half fill the chamber with saline. Undo the roller clamp and | |
|fill the giving set and recirculation connector with saline. Close the roller clamp | |
|on the I. V. administration set, ensuring there is no air present in the set. | |
|Press the reinfusion button | |
|Select NaCl | |
|Follow on screen instructions for Nacl | |
|Close the pinch clamps on the arterial blood and arterial access line. | |
|Disconnect the arterial blood line from the arterial needle and attach it to the | |
|recirculation connectorat the end of the saline bag | |
|Once connected unclamp arterial clamps and open the roller clamp on the saline | |
|administration set and press ok | |
|Rinse Back Blood | |
|Dialysis ends when clear fluid is detected below the bubble trap. | |
|Press continue if more is required and stop the pump using on screen control. | |
|Disconnect patient. | |
|Press remove lines button. | |
|Deal with access as appropriate. | |
|Empty dialyzer | |
|Replace concentrate suction tube and remove bibag when empty. | |
|Remove all blood lines ensuring substitute port is firmly closed. | |
|Close doors –machine will automatically go into disinfect. | |
| | |
|Procedure |MONITOR THE DIALYSIS TREATMENT |
| | |
|Description | |
| | |
| | |
|Purpose | |
| | |
| | |
|Reference | |
| | |
| |This procedure describes the dialysis parameters and safety monitors displayed during the treatment. |
| | |
| |Standard operating procedures in a clinic dictate that treatment records are documented and maintained. |
| | |
| |Fresenius 5008 Operators Manual |
|Supplies |1 – Haemodialysis flow sheet |
| |1 – Patient prescription |
|Procedure |Rationale |
|Review the treatment parameters on the screen. |Operator can verify that treatment information displayed on the |
|Dialysis temperature and conductivity |screen matches the prescription or treatment settings. Operator|
|Blood and dialysate flow rate settings |can observe that the blood and dialysate circuit monitoring |
|Fluid removed and ultrafiltration rate |system does not exceed prescription limits. |
|Treatment time remaining | |
|Arterial pressure | |
|Venous pressure | |
|Arterial and venous pressure trending on treatment key | |
|Heparin information | |
|OCM monitoring (OCM key – personal data for details of Kt/v | |
| | |
|If necessary press the Dialysate menu, UF menu or treatment menu | |
|Procedure |MUSCLE CRAMPS |
| | |
|Description | |
| | |
|Purpose | |
| | |
| | |
|Reference | |
| | |
| |This procedure describes how to treat cramping during dialysis. |
| | |
| |Muscle cramps can be caused by rapid removal of fluid or change in target weight. |
|Procedure |Rationale |
|Press the options key. | |
|Press the emergency key. Turn UF off. |Target or dry weight may need re-evaluation. |
|Press the bolus key. | |
|If necessary decrease the target fluid to remove, change back flush interval to | |
|zero or extend patient’s treatment. | |
|If necessary give further bolus as above | |
|Document observations. Document total solution infusion given and any treatment | |
|setting changes. | |
|Notify the renal unit. | |
|Inform the renal unit as your target weight may need changing. | |
|Procedure |NEEDLE INFILTRATION |
| | |
|Description | |
| | |
| | |
|Purpose | |
| | |
| | |
| | |
|Reference | |
| | |
| |This procedure describes what to do in the event of an arterial or venous needle infiltration (needle blow) or hematoma. |
| | |
| |During needle insertion the needle tip may go into the graft or vein through the other side allowing blood to escape into |
| |the surrounding tissues. An infiltrated needle (blown needle) requires another needle stick. |
| | |
|Procedure |Rationale |
|Press the pump to stop immediately |Stops the blood pump and closes the arterial and venous clamps. |
|Press the options key. | |
|Press the circulation key to recirculate whilst addressing the blow. | |
| |Minimizes the risk of bleeding during dialysis. |
|If heparin has not been given, pull the needle and hold pressure. | |
|If infiltration (needle blow) occurs after heparin has been given, leave needle | |
|in. | |
|If arterial needle infiltrated (blown), insert the new needle below the | |
|infiltration (blow). |To prevent the unaffected needle from clotting during |
|If the venous needle infiltrated (blown), insert the new needle above the |recirculation. |
|infiltration (blow). | |
|Prior to inserting a new needle, flush the unaffected needle with 10mls of | |
|saline. | |
|Press the Green key to resume operation. | |
PROCEDURE FOR THE INSERTION OF SHARP NEEDLES FOR DIALYSIS
|Action |Rationale |
|Gather equipment: |To ensure that all equipment is at hand. |
|Basic procedure pack | |
|2x 10ml syringes |To prime needles |
|10mls 0.9% saline |Needle size is individual e.g. 15gauge |
|2x dialysis needles |A tourniquet is not needed for PTFE grafts |
|Tourniquet |To administer heparin |
|Alcohol wipe | |
|2ml syringe |To secure needles |
|Green needle | |
|Adhesive tape | |
|2.Assessment and disinfection of fistula | |
|Wash Hands as instructed | |
|Examine fistula/graft prior to needle insertion. |To prevent contamination |
|Use alcowipe/trigene wipes to clean fistula. Allow to dry |Avoid any areas that feel problematic e.g. lump/,bumps, |
| |infection. |
|3.Insertion of needles | |
| |To remove any bacteria. |
|Place the 10ml syringes on to the needles after priming | |
|syringes with saline |Applying pressure engorges the fistula with blood to make it |
|Place tourniquet onto the upper arm and apply moderate |firm and assist needle insertion |
|pressure- fistulas only |This applies to fistulas and not PTFE grafts |
|Insert the Arterial needle first |The “flash back” of blood confirms you are in the correct area |
|Holding the needle by its wings , with the bevel of the needle| |
|facing up insert the needle at an angle of 25 degrees and a | |
|“flash back” of blood should be obtained | |
|Release the pressure on the tourniquet | |
|Thread the length of the needle into the fistula/graft and |The blood should flow in and out of the syringe freely. If it |
|confirm the flow of the blood by pulling and pushing back on |does not, then withdraw the needle slightly and rethread at a |
|the syringe |slightly different angle. i.e. deeper/more superficial. No pain|
| |should be felt at this point |
| |To prevent air embolism |
|.Ensure no air is present prior to pushing back blood into the| |
|fistula/graft. | |
|Clamp the needle tubing and tape securely | |
| | |
|Confirm the blood flow again with the syringe |To prevent blood loss and needle becoming dislodged |
| | |
| |If the tape is too tight and the fistula is superficial it may |
| |impede the flow of the blood. Adjust tape if necessary |
| | |
| | |
|4. Repeat the above steps to insert the venous needle | |
|5.Draw up prescribed heparin using 2ml syringe and green |To prevent clotting of the dialysis circuit. |
|needle. Remove 10ml syringe from the arterial needle and | |
|attach heparin syringe. Inject heparin prior to connection to | |
|dialysis circuit. | |
|6.Dispose of all materials safely as per policy |Prevent cross infection and contamination |
|NB.The vibration or “thrill” of the fistula should be felt for|The fistula may be at risk of stopping or have stopped. |
|every day. If the “thrill” has diminished or is absent contact| |
|the Renal Unit immediately. | |
CANNULATION OF AV FISTULA USING BUTTONHOLE TECHNIQUE STANDARD AV FISTULA NEEDLES
What is Buttonhole Needling?
With this technique the haemodialysis needles are inserted into the same spot, at the exact same angle and the exact same depth for each dialysis treatment. The buttonhole cannulation site needs to be established by the same person cannulating the site every time for approximately 8-10 cannulations until the track is established.
A thorough assessment of the fistula must be completed to evaluate any potential or existing problems the access may possess. The site for buttonhole cannulation must allow for the needles to be placed a minimum of 6cms apart and in an area of the fistula that allows ease of insertion for both the nurse and the self cannulator.
• With NOTE : It takes approximately six to eight cannulations using a sharp needle to create a scar tissue tunnel track in a given site. Once a scar tissue tunnel track is well formed Dull Bevel needles can be used
|ACTION |RATIONALE |
|Equipment | |
|2x AV fistula needles |Needle size as prescribed |
|2x 10ml syringes | |
|10mls 0.9% saline |To prime needles |
|Basic procedure pack | |
|Tourniquet |If required |
|Sterile gauze |To soak scabs to enable easy removal, if not using Emla cream |
|10mls 0.9% saline solution |To disinfect skin |
|Alcowipe/Trigene wipes | |
|2ml syringe |To administer prescribed heparin |
|Green needle | |
|1. Select cannulation sites carefully. Consider straight areas, |To avoid any potential cannulation/flow problems. |
|needle orientation, and the ability of the patient to |The participation of a carer in the cannulation process is an |
|self-cannulate. Sites should be selected in an area without |advantage. |
|aneurysms and with a minimum of two inches between the tips of the | |
|needles. | |
|2. Remove any scabs over the cannulation sites using an aseptic |Prevent infection and trauma to the insertion site. |
|technique as per renal unit protocol. | |
|3. Disinfect the cannulation sites using alcohol wipe. | |
|4. Prime each needle with 5mls saline. |Helps prevent the tip of the needle clotting during insertion. |
|.Using a sharp AV fistula needle, grasp the needle wings, and | |
|removes the tip protector. | |
|Align the needle cannula, with the bevel facing up, over the | |
|cannulation site and pull the skin slightly taut. | |
|5. Cannulate the site at a 25-30 degree angle. |A tract will only be properly formed using a single cannulator, thus|
|It is important to cannulate the constant- site in the exact same |removing any possible errors. |
|place, using the same insertion angle and depth of penetration.* | |
|This requires that a single cannulator perform all cannulations | |
|until the sites are well established. | |
|6. A flashback of blood indicates the needle is in the access. Lower|Lowering the needle angle prevents infiltration of the vessel wall. |
|the angle of insertion. Continue to advance the needle into the | |
|fistula until it is positioned appropriately within the vessel. | |
|7. Securely tape into position and repeat. | |
CANNULATION OF AV FISTULA USING BUTTONHOLE TECHNIQUE WITH DULL BEVEL NEEDLES
|ACTION |RATIONALE |
|Equipment | |
|2x AV fistula dull needles |Needle size as prescribed |
|2x 10ml syringes | |
|10 mls 0.9% saline |To prime needles |
|Basic procedure pack | |
|Tourniquet | |
|Sterile gauze |To soak scabs for easy removal if not using Emla cream |
|20ml 0.9% saline solution | |
|Alcowipe/Trigene wipes |To administer heparin as prescribed |
|2ml syringe | |
|1 green needle | |
|1. Remove scabs over cannulation sites using aseptic technique as |Prevent infection and to enable insertion of dull needles. |
|per renal unit protocol. | |
|2.Disinfect cannulation sites using alcowipe | |
|3. Grasp the needle wings, and remove the tip protector. Align the | |
|needle cannula, with the bevel facing up, over the cannulation site | |
|and pull the skin taut. | |
|4. Carefully insert the needle into the established cannulation | |
|site. Advance the needle along the scar tissue tunnel track. If mild| |
|to moderate resistance is met while attempting to insert the needle,| |
|rotate the needle as you advance it using gentle pressure. | |
|5. A flashback of blood indicates when the needle is in the access. | |
|Lower the angle of insertion. Continue to advance the needle into | |
|the AV fistula until it is in the appropriate position within the | |
|vessel. | |
|6. Securely tape into position and repeat. | |
|Procedure |POWER LOSS |
| | |
|Description | |
| | |
| | |
|Purpose | |
| | |
| | |
|Reference | |
| | |
| |This procedure describes how to return the patient’s blood in the event of power loss. |
| | |
| |The dialysis machine will have battery back up and then will switch itself off. The UF pump stops, substitute pump stops and|
| |dialysis flow off therefore manual wash back is necessary. |
| |Fresenius 5008 Operators Manual |
|Supplies |1 – 1,000 mL bag of sterile saline |
| |1 – IV administration set with recirculation connector attached. |
| |1 – IV pole |
|Procedure |Rationale |
|Note: Use alcohol rub and universal precautions as per training |Handling the blood tubing and saline administration sets improperly can |
|guidelines when performing this procedure. |cause machine contamination and / or patient injury. |
|Ensure all connections are secure when connecting and disconnecting the | |
|blood tubing set. | |
| | |
|Setup and connection | |
|(a)Hang the saline bag on the IV pole and | |
|Attach the IV administration set with attached recirculation connector to| |
|the bag. (Make sure connections are secure). Close roller clamp and half | |
|fill the chamber with saline. Undo the roller clamp and fill the giving | |
|set and recirculation connector with saline. Close the roller clamp on | |
|the I. V. administration set, ensuring there is no air present in the | |
|set. | |
|Press the Re-infusion button | |
|Select NaCl | |
|Press the 1/O buttonFollow on screen instructions | |
|(b)Close the clamps on the arterial blood tubing and arterial access | |
|line. | |
|Disconnect the arterial patient connector from the access line and attach| |
|it to the recirculation connector. | |
| | |
|To Rinse back blood | |
|Open the roller clamp on the saline administration set. | |
|Open the arterial clamp | |
|Once connected press ok. | |
|Dialysis ends when clear fluid is detected below the bubble trap. | |
|Press continue if more fluid is required and stop the pump using on | |
|screen control. | |
|Disconnect patient . | |
|Press remove lines. | |
|Deal with access as appropriate. | |
|Empty dialyzer. | |
|Replace concentrate suction tube and remove bibag when empty. | |
|Remove all blood lines ensuring substitute port is firmly closed . | |
|Close the door and the machine will automatically go into disinfect. | |
|If power is lost and the machine turns off, when power is restored select| |
|the cleaning menu and select heat disinfect program. | |
|Procedure |PREPARE FOR DIALYSIS |
| | |
|Description | |
| | |
| | |
|Purpose | |
| | |
|Reference | |
| | |
| |This procedure describes how to connect a patient to the PHD System for dialysis. |
| | |
| |Standard operating |
| | |
| |Fresenius 5008 Operators Manual and 5008 Therapy system Brief Operating Guide |
| |Insertion of needles for dialysis procedure |
|Supplies |1 – sharps container |
| |Tape - narrow and wide |
| |Tourniquet |
| |2 x dialysis needles |
| |Sterile green needle |
| |1 x basic procedure pack |
| |1 x alcohol wipe Trigene wipes |
| |1 x 10 ml syringes 1 x 30 ml leur lock syringe |
| |2 x Heparin 5000 iu per/ml or Clexane |
| |Sterile saline administration set with recirculation connector attached |
| |1,000 mL bag of sterile saline |
| |Liquid Hand Washand Alcohol rub |
| |Concentrate and Bibag |
| |Dialyser and pack of 5008 BVM Lines |
|Procedure |Rationale |
|Note: Using Trigene and Alcohol rub and universal precautions when performing | |
|this procedure as explained during training. | |
| | |
|Switch on the machine | |
|Select treatment ( or disinfection ) | |
|Connect concentrate and bibag (ensure correct concentrate is selected in | |
|dialysate menu). | |
|T1 test starts automatically. | |
|Follow instructions for lining. Arterial lines first. Make sure you hear the | |
|sound when inserting the red plastic ‘alpha clip’ into the lineguide. Make sure| |
|placed correctly, dome in pressure device and line in arterial clamp. | |
|Insert heparin syringe correctly and securely. | |
|Attach venous line ensuring line below venous chamber is firmly placed in the | |
|blood/air detector groove. | |
|Place safe line ( sub tubing ) into HDF pump, ensure the sound is generated on | |
|insertion of the clear plastic ‘alpha ‘ clip into the line guide, then connect | |
|the arterial line. | |
|Connect the rinse connector to venous line. | |
|On completion of T1-test, place insert safeline into the upper port (BLUE) and | |
|the rinse connector ( on the venous line) into the lower rinse port (GREY). | |
|Any damaged items, cracked connections or casings, necessitates replacement of | |
|that item. | |
|Close the doors. | |
|Connect dialysate arms ( RED to BLUE BLUE TO RED ). | |
|Press the blood pump button on the screen to commence prime. | |
|Priming is complete when volume has reached 1000mls. | |
|Enter U/F, treatment time, heparin data, Check conductivity, temperature, time | |
|and dialysate tank. | |
|When full prime volume has been achieved stop the prime by pressing the blood | |
|pump button on the screen. | |
|A message choices- ‘continue’ or ‘exit’ are displayed, press “exit”. | |
|Follow on screen instructions | |
|Hang ‘A’ and ‘V’ lines on the dialysate armand clamp both lines. | |
|Insert needles as per policy. | |
|Complete checklist to ensure safety i.e. | |
|Isolators are securely attached | |
|Clamps on venous ports are closed. | |
|Blood pressure has been checked. | |
|Heparin is set correctly and clamp removed. | |
|U/F has been set to correct amount. | |
|Dialysate has been been set to correct time. | |
|Dialysate arms are attached to dialyzer. | |
|Lines and needles are free from air. | |
|Venous bubble trap is filled 1cm from the top. | |
|Connect access to ‘A’ and ‘V’ lines. | |
|Follow onscreen instructions for hook-up. | |
|Ensure the rinse port is closed, close the doors, open clamps and confirm start| |
|blood pump message. | |
|Dialysis commences when blood is sensed below the venous trap, confirm with | |
|button below message. | |
|Increase blood flow to prescribed level. | |
|U/F starts automatically if data is already set. | |
|Heparin starts automatically, bolus needs to be given if required. | |
|Check U/F has been switched on. | |
|Spare bag of saline is within reach. | |
|Spare syringes, clamps,tape,cottonwool and gauze are within reach. | |
|Baseline observations are very important and values should be recorded i.e. | |
|start time,blood flow rate, Blood Pressure, Arterial and Venous Pressures, U/F | |
|rate, TMP. | |
|Procedure |RINSEBACK POST-DIALYSIS |
|Description | |
| | |
| | |
| | |
|Purpose | |
| | |
| | |
|Reference | |
| |This procedure describes how to rinse back the patient’s blood. |
| | |
| | |
| | |
| | |
| | |
| | |
| |Fresenius 5008 Operators Manual |
|Supplies | |
|Procedure |Rationale |
|Note: Use aseptic technique and universal precautions when performing this | |
|procedure. Ensure all connections are secure when connecting and disconnecting | |
|the blood tubing set. | |
|When treatment goal is reached, collect equipment and prepare for | |
|disconnection. | |
|message will appear on screen prompting next phase. | |
|Press reinfusion and follow onscreen instructions. | |
|Once connected press ok ( only press NaCl if you have run out of acid/bicarb | |
|and need to use manual saline to washback). | |
|Dialysis ends when clear fluid is detected below the bubble trap. | |
|Press continue if more is required and stop the pump using on screen control, | |
|clamp venous blood tubing. | |
|Disconnect patient then press remove lines button. | |
|Deal with access as appropriate. | |
|Empty dialyzer. | |
|Replace concentrate suction tube and remove bibag when empty. | |
|Remove all blood lines ensuring substitute port is firmly closed. | |
|Close doors . Machine automatically goes into hot disinfect. | |
|EARLY DISCONNECTION | |
|Press reinfusion button | |
|Press ‘1/O’ button. | |
|Follow the above instructions from 4 onwards | |
|Procedure |ARTERIAL PRESSURE DEVICE DOES NOT OPEN WHEN LINE GUIDE IS INSERTED |
|Description | |
| | |
| | |
| | |
|Purpose | |
| | |
| | |
|Reference | |
| | |
| |To ensure arterial pressure devise opens to allow the line guide to be inserted or removed. |
|Supplies |30 ml syringe |
|Procedure |Rationale |
|1.Close and reopen door, press line guide to generate sound. | |
|2.If this does not resolve problem, open diasafe housing and locate small tube | |
|above the filters and instill approximately 30ml of air. This will push the | |
|mechanism forward. | |
|Procedure |HAEMOCONCENTRATION WARNING |
|Description | |
| | |
| | |
| | |
|Purpose | |
| | |
| | |
|Reference | |
| |During haemodialysis, the pressure across the membrane (transmembrane pressure) is related to it’s ability to allow fluid to|
| |pass through it. This will be higher or rise as it becomes more difficult for fluid to pass across the dialyser. |
|Supplies |None |
|Procedure |Rationale |
|The pressure is likely to rise if; |In Haemodiafiltration, the Uf rates are higher in the kidney to |
|the patient is nearing their dry weight and fluid is no longer available to |create convection. A formula is used to calculate the safe HDF |
|remove |fraction and on 5008, this is calculated for you. In post dilution |
|the patient has poor refilling |HDF, there is a risk of haemoconcentration to the point that the |
|Arterial pressure is low ( ................
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